Provider Demographics
NPI:1467883959
Name:SELCON, SANFORD
Entity Type:Individual
Prefix:
First Name:SANFORD
Middle Name:
Last Name:SELCON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8420 QUAIL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-6066
Mailing Address - Country:US
Mailing Address - Phone:916-791-2895
Mailing Address - Fax:
Practice Address - Street 1:8420 QUAIL OAKS DR
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-6066
Practice Address - Country:US
Practice Address - Phone:916-791-2895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29359207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology