Provider Demographics
NPI:1497756555
Name:SANDERS, JESSE DAVID JR (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:DAVID
Last Name:SANDERS
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1172 N MACLAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-1328
Mailing Address - Country:US
Mailing Address - Phone:818-898-1388
Mailing Address - Fax:818-365-4031
Practice Address - Street 1:12756 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1626
Practice Address - Country:US
Practice Address - Phone:818-896-0531
Practice Address - Fax:818-896-5850
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG55931207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C46673Medicare UPIN