Provider Demographics
NPI:1710952676
Name:MARCUSON, SANFORD KENT (MD)
Entity Type:Individual
Prefix:
First Name:SANFORD
Middle Name:KENT
Last Name:MARCUSON
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 1:860 OMNI BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4430
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:757-232-8875
Practice Address - Street 1:6601 MOORETOWN RD
Practice Address - Street 2:SUITE 400
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2196
Practice Address - Country:US
Practice Address - Phone:757-645-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101227468207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00315325OtherRR/MEDICARE
VA0403049OtherUNITED HEALTHCARE
VA454080OtherANTHEM BLUE CROSS BLUE SH
VA005870411Medicaid
VA0410632001OtherCIGNA HEALTHCARE
VA133641808OtherTRICARE
VA29088OtherSENTARA/OPTIMA
VA110008349Medicare ID - Type Unspecified
VA005870411Medicaid