Provider Demographics
NPI:1952484347
Name:SANDERS, MARK ISAAC SR (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ISAAC
Last Name:SANDERS
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 W TEMPLE ST
Mailing Address - Street 2:5606
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-5421
Mailing Address - Country:US
Mailing Address - Phone:213-413-1133
Mailing Address - Fax:213-413-1101
Practice Address - Street 1:1711 W TEMPLE ST
Practice Address - Street 2:5606
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5421
Practice Address - Country:US
Practice Address - Phone:213-413-1133
Practice Address - Fax:213-413-1101
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38138174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A3813800Medicaid
CA0A3813800Medicaid
CAF52347Medicare UPIN