Provider Demographics
NPI:1346333721
Name:SANDEFUR, ERIC TODD (DO)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:TODD
Last Name:SANDEFUR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 POCAHONTAS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814
Mailing Address - Country:US
Mailing Address - Phone:541-523-1797
Mailing Address - Fax:541-523-1799
Practice Address - Street 1:3325 POCAHONTAS RD
Practice Address - Street 2:SUITE B
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814
Practice Address - Country:US
Practice Address - Phone:541-523-1797
Practice Address - Fax:541-523-1799
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD020320207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR645470Medicaid
OR645470Medicaid
020WFBTDBMedicare ID - Type Unspecified