Provider Demographics
NPI:1508828971
Name:SANDERA, MARISA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:
Last Name:SANDERA
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 1:134 MENGER SPGS
Mailing Address - Street 2:SUITE 1120
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-7218
Mailing Address - Country:US
Mailing Address - Phone:210-593-5700
Mailing Address - Fax:210-593-5992
Practice Address - Street 1:134 MENGER SPGS
Practice Address - Street 2:SUITE 1120
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-7218
Practice Address - Country:US
Practice Address - Phone:210-593-5700
Practice Address - Fax:210-593-5992
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0556207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1745390-02OtherCSHCN
TXP00269397OtherRR/MEDICARE
TX1745390-03Medicaid
TX1745390-01Medicaid
TX8S1845OtherBLUE SHIELD
TX1745390-03Medicaid
TX8S1845OtherBLUE SHIELD
TX8L0903Medicare PIN