Provider Demographics
NPI:1629042304
Name:SANFORD, BENJAMIN F JR (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:F
Last Name:SANFORD
Suffix:JR
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 1:107 BRANDON RD
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2521
Mailing Address - Country:US
Mailing Address - Phone:662-324-1291
Mailing Address - Fax:662-324-2196
Practice Address - Street 1:107 BRANDON RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2521
Practice Address - Country:US
Practice Address - Phone:662-324-1291
Practice Address - Fax:662-324-2196
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS8043207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114992Medicaid
MS110001579Medicare ID - Type Unspecified
MS00114992Medicaid