Provider Demographics
NPI:1336241363
Name:SANDERSON, JEFFREY ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ROBERT
Last Name:SANDERSON
Suffix:
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 1:4 PARK LANE
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776
Mailing Address - Country:US
Mailing Address - Phone:860-354-2241
Mailing Address - Fax:860-350-8660
Practice Address - Street 1:4 PARK LANE
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776
Practice Address - Country:US
Practice Address - Phone:860-354-2241
Practice Address - Fax:860-350-8660
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT24946208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
706114OtherCONNECTICARE
LIS011OtherOXFORD
041378OtherHEALTHNET
56010024946CT2OtherANTHEM NATIONAL ACCOUNT
CT001249465Medicaid
CT010024946CT02OtherBLUE SHEILD
2043999OtherAETNA
2248667002OtherCIGNA
500HBC186CT01OtherBLUE CARE FAMILY PLAN
C59605Medicare UPIN
500HBC186CT01OtherBLUE CARE FAMILY PLAN
LIS011OtherOXFORD