Provider Demographics
NPI:1417211772
Name:SANDERS PODIATRY PLLC
Entity Type:Organization
Organization Name:SANDERS PODIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:605-880-5874
Mailing Address - Street 1:909 13TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-1069
Mailing Address - Country:US
Mailing Address - Phone:605-880-5874
Mailing Address - Fax:605-753-1099
Practice Address - Street 1:909 13TH AVE NW
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-1069
Practice Address - Country:US
Practice Address - Phone:605-880-5874
Practice Address - Fax:605-753-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-01
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD208213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS106266Medicare UPIN