Provider Demographics
NPI:1538125174
Name:SANDER, GARY EDWARD (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:EDWARD
Last Name:SANDER
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 BEVERLY GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-1903
Mailing Address - Country:US
Mailing Address - Phone:504-458-5717
Mailing Address - Fax:504-835-7019
Practice Address - Street 1:2820 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6302
Practice Address - Country:US
Practice Address - Phone:504-821-8158
Practice Address - Fax:504-304-1927
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012458207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1303496Medicaid
LA5K403Medicare PIN
LA1303496Medicaid