Provider Demographics
NPI:1700846870
Name:SANDERSON, MARVIN BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:BRUCE
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 1:500 S UNIVERSITY AVE STE 701
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5309
Mailing Address - Country:US
Mailing Address - Phone:501-664-5119
Mailing Address - Fax:501-664-4209
Practice Address - Street 1:500 S UNIVERSITY AVE STE 701
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5309
Practice Address - Country:US
Practice Address - Phone:501-664-5119
Practice Address - Fax:501-664-4209
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4641207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104566001Medicaid
AR54670Medicare ID - Type Unspecified