Provider Demographics
NPI:1558431163
Name:SANDERS, SCOTT EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:EDWARD
Last Name:SANDERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-3606
Mailing Address - Country:US
Mailing Address - Phone:228-467-1020
Mailing Address - Fax:228-467-7258
Practice Address - Street 1:299 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-3606
Practice Address - Country:US
Practice Address - Phone:228-467-1020
Practice Address - Fax:228-467-7258
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS755152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist