Provider Demographics
NPI:1407844749
Name:SANDLUND, KRISTOFER GIBSON (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTOFER
Middle Name:GIBSON
Last Name:SANDLUND
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 1:1215 NEWARK ROAD
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-2861
Mailing Address - Country:US
Mailing Address - Phone:740-452-7359
Mailing Address - Fax:740-452-7309
Practice Address - Street 1:1215 NEWARK ROAD
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2861
Practice Address - Country:US
Practice Address - Phone:740-452-7359
Practice Address - Fax:740-452-7309
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048739S207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0549142Medicaid
OH0549142Medicaid
OHSA0547404Medicare ID - Type Unspecified