Provider Demographics
NPI:1346726098
Name:SANFORD, MITCHELL ADAM
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:ADAM
Last Name:SANFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12057 HIGHWAY 49 STE C
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3177
Mailing Address - Country:US
Mailing Address - Phone:228-832-9385
Mailing Address - Fax:888-498-3529
Practice Address - Street 1:12057 HIGHWAY 49 STE C
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3177
Practice Address - Country:US
Practice Address - Phone:228-832-9385
Practice Address - Fax:888-498-3529
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS29354207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine