Provider Demographics
NPI:1508903535
Name:SANFORD, SUE ANN (OD)
Entity Type:Individual
Prefix:
First Name:SUE ANN
Middle Name:
Last Name:SANFORD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 PORTER CREEK DR STE 217
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-2336
Mailing Address - Country:US
Mailing Address - Phone:817-847-7747
Mailing Address - Fax:817-847-7783
Practice Address - Street 1:2301 PORTER CREEK DR STE 217
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-2336
Practice Address - Country:US
Practice Address - Phone:817-847-7747
Practice Address - Fax:817-847-7783
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004414152W00000X
FLOPC 4240152W00000X
TX6766T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist