Provider Demographics
NPI:1346200987
Name:SANDER, RICKIE (MD)
Entity Type:Individual
Prefix:
First Name:RICKIE
Middle Name:
Last Name:SANDER
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 1:3599 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 503
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4252
Mailing Address - Country:US
Mailing Address - Phone:904-399-2829
Mailing Address - Fax:904-399-2905
Practice Address - Street 1:3599 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 503
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4252
Practice Address - Country:US
Practice Address - Phone:904-399-2829
Practice Address - Fax:904-399-2905
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME35606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15584EMedicare PIN