Provider Demographics
NPI:1922038884
Name:SANFORD, DONALD L (OD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:SANFORD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1266
Mailing Address - Street 2:
Mailing Address - City:KETTLE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:99141-1266
Mailing Address - Country:US
Mailing Address - Phone:509-634-2937
Mailing Address - Fax:509-634-2990
Practice Address - Street 1:29 NESPELEM/SAN POIL ST
Practice Address - Street 2:
Practice Address - City:NESPELEM
Practice Address - State:WA
Practice Address - Zip Code:99155
Practice Address - Country:US
Practice Address - Phone:509-364-2937
Practice Address - Fax:509-364-2990
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1447152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7100100Medicaid
8HBG64Medicare ID - Type Unspecified
TO2503Medicare UPIN