Provider Demographics
NPI:1558354977
Name:SANDERSON, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
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 1:405 TALLMADGE RD
Mailing Address - Street 2:STE. 120
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-3362
Mailing Address - Country:US
Mailing Address - Phone:330-784-9306
Mailing Address - Fax:330-475-7544
Practice Address - Street 1:405 TALLMADGE RD
Practice Address - Street 2:STE. 120
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-3362
Practice Address - Country:US
Practice Address - Phone:330-784-9306
Practice Address - Fax:330-475-7544
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076954S208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4072873OtherMEDICARE ID
OH4072871OtherMEDICARE ID
OH2333817Medicaid
OH2333817Medicaid