Provider Demographics
NPI:1497754725
Name:SANFORD, SCOTT ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALLEN
Last Name:SANFORD
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 1:5550 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-8701
Mailing Address - Country:US
Mailing Address - Phone:772-460-9227
Mailing Address - Fax:772-460-9292
Practice Address - Street 1:5550 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-8701
Practice Address - Country:US
Practice Address - Phone:772-460-9227
Practice Address - Fax:772-460-9292
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL592770836OtherTAX ID FOR TRICARE
FLA79777Medicare UPIN