Provider Demographics
NPI:1376588533
Name:SANDERSON, DOROTHY JENSEN (MD)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:JENSEN
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DOROTHY
Other - Middle Name:ANN
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0698
Mailing Address - Country:US
Mailing Address - Phone:602-263-1200
Mailing Address - Fax:602-200-5383
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-200-5383
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4735207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ740789Medicaid
H43891Medicare UPIN