Provider Demographics
NPI:1790909588
Name:SANDERS, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:SANDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BAY
Other - Middle Name:MEDICAL
Other - Last Name:CORP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2270
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94966-2270
Mailing Address - Country:US
Mailing Address - Phone:510-375-2836
Mailing Address - Fax:510-653-7159
Practice Address - Street 1:3706 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2418
Practice Address - Country:US
Practice Address - Phone:510-331-2788
Practice Address - Fax:510-653-7159
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29998208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ35070ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NO.
A34086Medicare UPIN
CA00C299981Medicare ID - Type UnspecifiedMEDICARE 3706 TELEGRAPH