Provider Demographics
NPI:1942207642
Name:SANDERSON, DAVID GREGORY (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GREGORY
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:ST MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-1708
Mailing Address - Country:US
Mailing Address - Phone:814-834-7240
Mailing Address - Fax:814-781-6581
Practice Address - Street 1:238 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ST MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-1708
Practice Address - Country:US
Practice Address - Phone:814-834-7240
Practice Address - Fax:814-781-6581
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004253L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016017850007Medicaid
PA5660590001Medicare NSC
PAU62112Medicare UPIN
PA884487Medicare ID - Type Unspecified