Provider Demographics
NPI:1669414678
Name:DUKE, SANFORD G (MD)
Entity type:Individual
Prefix:
First Name:SANFORD
Middle Name:G
Last Name:DUKE
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 1:540 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3202
Mailing Address - Country:US
Mailing Address - Phone:478-743-8953
Mailing Address - Fax:478-743-1963
Practice Address - Street 1:540 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-3202
Practice Address - Country:US
Practice Address - Phone:478-743-8953
Practice Address - Fax:478-743-1963
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA49885207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6372095-002OtherCIGNA
GA00904307AMedicaid
GA821361OtherB/C B/S
GA00904307AMedicaid
GA04BDCFXMedicare PIN