Provider Demographics
NPI:1366479818
Name:SANDBERG, KARL P (MD)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:P
Last Name:SANDBERG
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:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72833-0639
Mailing Address - Country:US
Mailing Address - Phone:479-495-2241
Mailing Address - Fax:479-495-6290
Practice Address - Street 1:402 S SCENIC 7 DR
Practice Address - Street 2:
Practice Address - City:OLA
Practice Address - State:AR
Practice Address - Zip Code:72853-8852
Practice Address - Country:US
Practice Address - Phone:479-489-5126
Practice Address - Fax:479-489-5174
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1317207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131589001Medicaid
A47502Medicare UPIN
AR5K484Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER