Provider Demographics
NPI:1457449035
Name:SANDERSON, JOHN R (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12289 LEAVITT RD
Mailing Address - Street 2:UNIT D
Mailing Address - City:OBERLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44074-8500
Mailing Address - Country:US
Mailing Address - Phone:440-775-1555
Mailing Address - Fax:440-775-1556
Practice Address - Street 1:12289 LEAVITT RD
Practice Address - Street 2:UNIT D
Practice Address - City:OBERLIN
Practice Address - State:OH
Practice Address - Zip Code:44074-8500
Practice Address - Country:US
Practice Address - Phone:440-775-1555
Practice Address - Fax:440-775-1556
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006510208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2131213Medicaid
OHG99750Medicare UPIN