Provider Demographics
NPI:1972962710
Name:SANDERS, BLAKE (DO)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:SANDERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:170 MEDICAL PARK RD STE 203
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8540
Mailing Address - Country:US
Mailing Address - Phone:980-550-2400
Mailing Address - Fax:980-550-2424
Practice Address - Street 1:170 MEDICAL PARK RD STE 203
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8540
Practice Address - Country:US
Practice Address - Phone:980-550-2400
Practice Address - Fax:980-550-2424
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS020540207N00000X
NC2021-03162207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology