Provider Demographics
NPI:1245678192
Name:SANDRIDGE, SEAN MACON
Entity type:Individual
Prefix:MR
First Name:SEAN
Middle Name:MACON
Last Name:SANDRIDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13114 MIDLOTHIAN TPKE
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-4206
Mailing Address - Country:US
Mailing Address - Phone:804-594-7020
Mailing Address - Fax:804-594-7021
Practice Address - Street 1:13114 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-4206
Practice Address - Country:US
Practice Address - Phone:804-594-7020
Practice Address - Fax:804-594-7021
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1260225171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VASS1787Medicaid