Provider Demographics
NPI:1851056667
Name:SANFORD, TONY D SR
Entity Type:Individual
Prefix:MR
First Name:TONY
Middle Name:D
Last Name:SANFORD
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-4044
Mailing Address - Country:US
Mailing Address - Phone:662-668-0662
Mailing Address - Fax:662-538-1193
Practice Address - Street 1:108 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-4044
Practice Address - Country:US
Practice Address - Phone:662-668-0662
Practice Address - Fax:662-538-1193
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN060294755172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver