Provider Demographics
NPI:1750382149
Name:SANDERFORD, JENNIFER M (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:SANDERFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BRUCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 167
Mailing Address - Street 2:
Mailing Address - City:CRESTED BUTTE
Mailing Address - State:CO
Mailing Address - Zip Code:81224-0167
Mailing Address - Country:US
Mailing Address - Phone:970-349-3333
Mailing Address - Fax:844-278-8636
Practice Address - Street 1:419 6TH STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:CRESTED BUTTE
Practice Address - State:CA
Practice Address - Zip Code:81224
Practice Address - Country:US
Practice Address - Phone:970-349-3333
Practice Address - Fax:844-278-8636
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38507208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO14857804Medicaid
H46319Medicare UPIN
COBB7305558Medicare ID - Type Unspecified