Provider Demographics
NPI:1770588014
Name:SANFORD, SCOTT (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:SANFORD
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 1:1343 BANDERA HWY
Mailing Address - Street 2:#205
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-9741
Mailing Address - Country:US
Mailing Address - Phone:432-349-9836
Mailing Address - Fax:
Practice Address - Street 1:1343 BANDERA HIGHWAY
Practice Address - Street 2:#205
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-9742
Practice Address - Country:US
Practice Address - Phone:432-349-9836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9646207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0065CKOtherBLUE CROSS BLUE SHIELD
TX132029304Medicaid
TX85081JMedicare PIN
TX132029304Medicaid