Provider Demographics
NPI:1508203449
Name:SANDERSON, REBECCA L (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 S WAKARA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1200
Mailing Address - Country:US
Mailing Address - Phone:801-587-5448
Mailing Address - Fax:
Practice Address - Street 1:590 S WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1200
Practice Address - Country:US
Practice Address - Phone:801-587-5448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-02
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101257948207X00000X
CODR.0062586207X00000X
UT12792808-1205207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery