Provider Demographics
NPI:1275630782
Name:SANDIFER, JOHN PETTEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PETTEY
Last Name:SANDIFER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3444 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3615
Mailing Address - Country:US
Mailing Address - Phone:318-473-9556
Mailing Address - Fax:318-441-8339
Practice Address - Street 1:213 SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457
Practice Address - Country:US
Practice Address - Phone:318-352-6120
Practice Address - Fax:318-352-6061
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06233R207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1334707Medicaid
55699Medicare ID - Type Unspecified
LA1334707Medicaid