Provider Demographics
NPI:1457483257
Name:SMALL, SANFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:SANFORD
Middle Name:
Last Name:SMALL
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 1:8610 S SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-4008
Mailing Address - Country:US
Mailing Address - Phone:310-670-1840
Mailing Address - Fax:310-670-4016
Practice Address - Street 1:8610 S SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-4008
Practice Address - Country:US
Practice Address - Phone:310-670-1840
Practice Address - Fax:310-670-4016
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31969174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA84289Medicare UPIN