Provider Demographics
NPI:1376631556
Name:SANDERS, HENRY JOHN IV (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:JOHN
Last Name:SANDERS
Suffix:IV
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 1:822 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-3824
Mailing Address - Country:US
Mailing Address - Phone:601-684-0220
Mailing Address - Fax:601-684-5573
Practice Address - Street 1:822 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3824
Practice Address - Country:US
Practice Address - Phone:601-684-0220
Practice Address - Fax:601-684-5573
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18847207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02984016Medicaid
MS02984016Medicaid
MS180000345Medicare ID - Type Unspecified