Provider Demographics
NPI:1972516763
Name:SANFORD, EDWARD W III (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:W
Last Name:SANFORD
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:10243 GENETIC CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-6310
Mailing Address - Country:US
Mailing Address - Phone:858-499-2600
Mailing Address - Fax:858-521-2019
Practice Address - Street 1:10243 GENETIC CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-6310
Practice Address - Country:US
Practice Address - Phone:858-499-2600
Practice Address - Fax:858-521-2019
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6963207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX69630Medicaid
CA00AX69630Medicaid
CAW20A6963BMedicare ID - Type Unspecified