Provider Demographics
NPI:1700846623
Name:SANDERS, CHANNING KYLE (MD)
Entity Type:Individual
Prefix:
First Name:CHANNING
Middle Name:KYLE
Last Name:SANDERS
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 1:8120 MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-3403
Mailing Address - Country:US
Mailing Address - Phone:985-223-8994
Mailing Address - Fax:985-655-8994
Practice Address - Street 1:8120 MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-3403
Practice Address - Country:US
Practice Address - Phone:985-223-8994
Practice Address - Fax:985-655-8994
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22360207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1492906Medicaid
5A765Medicare ID - Type Unspecified
LA1492906Medicaid