Provider Demographics
NPI:1407908270
Name:SANFORD, MARK T (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:SANFORD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E LONG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-5524
Mailing Address - Country:US
Mailing Address - Phone:248-879-2388
Mailing Address - Fax:248-879-3857
Practice Address - Street 1:101 E LONG LAKE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-5524
Practice Address - Country:US
Practice Address - Phone:248-879-2388
Practice Address - Fax:248-879-3857
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002762152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU35447Medicare UPIN