Provider Demographics
NPI:1518036151
Name:SANDERSON, JESSE FRANKLIN (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:FRANKLIN
Last Name:SANDERSON
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 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12200 WARWICK BLVD
Practice Address - Street 2:SUITE 480
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-2344
Practice Address - Country:US
Practice Address - Phone:757-534-5200
Practice Address - Fax:757-534-5830
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010331322085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00309248Medicare PIN
VA010166802Medicaid
VA007665U92Medicare PIN