Provider Demographics
NPI:1568559375
Name:SANDEEN, JOHN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:SANDEEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1000 WILLOW CREEK RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1645
Mailing Address - Country:US
Mailing Address - Phone:928-445-0300
Mailing Address - Fax:928-445-1674
Practice Address - Street 1:1000 WILLOW CREEK RD
Practice Address - Street 2:SUITE F
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1645
Practice Address - Country:US
Practice Address - Phone:928-445-0300
Practice Address - Fax:928-445-1674
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ13917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZMD13917Medicare ID - Type Unspecified
AZA.72937Medicare UPIN