Provider Demographics
NPI:1689608291
Name:SANDERS, JIM CLARK (DO)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:CLARK
Last Name:SANDERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 JEFFERSON SQ
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-1031
Mailing Address - Country:US
Mailing Address - Phone:636-586-6685
Mailing Address - Fax:636-586-2780
Practice Address - Street 1:12 JEFFERSON SQ
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-1031
Practice Address - Country:US
Practice Address - Phone:636-586-6685
Practice Address - Fax:636-586-2780
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMD2799207Q00000X
MO2009024604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268642Medicare Oscar/Certification
AK0000LGBTPMedicare ID - Type Unspecified