Provider Demographics
NPI:1669477824
Name:SANDERSON, AMY (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 INTERCOM DRIVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-2638
Mailing Address - Country:US
Mailing Address - Phone:256-772-2929
Mailing Address - Fax:256-772-2928
Practice Address - Street 1:102 INTERCOM DRIVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2638
Practice Address - Country:US
Practice Address - Phone:256-772-2929
Practice Address - Fax:256-772-2928
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-997-TA-564152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
102G700010OtherPTAN FOR ADVANCED EYECARE OF MADISON
102G700010OtherPTAN FOR ADVANCED EYECARE OF MADISON FOR MEDICARE