Provider Demographics
NPI:1801996715
Name:SANDERSON, DAVID J JR (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:SANDERSON
Suffix:JR
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 1:712 SOUTH CASCADE STREET
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2813
Mailing Address - Country:US
Mailing Address - Phone:218-736-8000
Mailing Address - Fax:218-736-8757
Practice Address - Street 1:712 SOUTH CASCADE STREET
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2813
Practice Address - Country:US
Practice Address - Phone:218-736-8000
Practice Address - Fax:218-736-8757
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21639207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN107116OtherUCAREMN
TX147662401Medicaid
IA0967679Medicaid
MNHP26725OtherHEALTHPARTNERS
WA0159499Medicaid
MN01-23706OtherMEDICABLC
MN265283800Medicaid
MN1008797OtherPREFERREDONE
MN62780SAOtherBCBS
NE41091744413Medicaid
MN01-00797OtherMEDICAFFMG & WRC
ND13217Medicaid
IA0967679Medicaid
MN089004588Medicare ID - Type UnspecifiedMEDICAREWRC
MN01-00797OtherMEDICAFFMG & WRC
MN62780SAOtherBCBS
MN080033385Medicare ID - Type UnspecifiedMEDICARERAILROAD