Provider Demographics
NPI:1659436293
Name:SANDERSON, VIRGIL THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:VIRGIL
Middle Name:THOMAS
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 1:8515 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-1849
Mailing Address - Country:US
Mailing Address - Phone:718-523-7186
Mailing Address - Fax:718-523-7186
Practice Address - Street 1:8515 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435-1849
Practice Address - Country:US
Practice Address - Phone:718-523-7186
Practice Address - Fax:718-523-7186
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01000908Medicaid
NY01000908Medicaid