Provider Demographics
NPI:1376578088
Name:SANSARICQ, JEAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:A
Last Name:SANSARICQ
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 7627
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36670
Mailing Address - Country:US
Mailing Address - Phone:251-633-0573
Mailing Address - Fax:251-633-7367
Practice Address - Street 1:524 STANTON RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2343
Practice Address - Country:US
Practice Address - Phone:251-479-0058
Practice Address - Fax:251-479-1585
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17868174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009982570Medicaid
AL51506914OtherBCBS PROVIDER NUMBER
AL043630600OtherTAX ID NUMBER