Provider Demographics
NPI:1639334337
Name:SANDERSON, SCOTT R (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
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 1:349 AUWINALA RD
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-3434
Mailing Address - Country:US
Mailing Address - Phone:253-777-9630
Mailing Address - Fax:888-449-0690
Practice Address - Street 1:349 AUWINALA RD
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-3434
Practice Address - Country:US
Practice Address - Phone:253-777-9630
Practice Address - Fax:888-449-0690
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2016-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15712207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine