Provider Demographics
NPI:1770623449
Name:SANDERS, GARY W (DC, FASA)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:SANDERS
Suffix:
Gender:M
Credentials:DC, FASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4712 BOAT CLUB RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-2002
Mailing Address - Country:US
Mailing Address - Phone:817-237-2930
Mailing Address - Fax:817-237-4143
Practice Address - Street 1:4712 BOAT CLUB RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-2002
Practice Address - Country:US
Practice Address - Phone:817-237-2930
Practice Address - Fax:817-237-4143
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4758111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB129427OtherMEDICARE PTAN
TXTXB129427OtherMEDICARE PTAN