Provider Demographics
NPI:1750680575
Name:JAMES R. SANDERSON, O.D., P.C.
Entity Type:Organization
Organization Name:JAMES R. SANDERSON, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST -PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:708-349-7571
Mailing Address - Street 1:9924 W 143RD PL
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2567
Mailing Address - Country:US
Mailing Address - Phone:708-349-7571
Mailing Address - Fax:708-460-9355
Practice Address - Street 1:9924 W 143RD PL
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2567
Practice Address - Country:US
Practice Address - Phone:708-349-7571
Practice Address - Fax:708-460-9355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-006366152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1184654733OtherNPI
ILT36704Medicare UPIN