Provider Demographics
NPI:1831183037
Name:SANNER, MARTY KELLY (MD)
Entity type:Individual
Prefix:DR
First Name:MARTY
Middle Name:KELLY
Last Name:SANNER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4202 SW LEE BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-8300
Mailing Address - Country:US
Mailing Address - Phone:580-353-7777
Mailing Address - Fax:580-248-8313
Practice Address - Street 1:4202 SW LEE BLVD
Practice Address - Street 2:STE 104
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-8300
Practice Address - Country:US
Practice Address - Phone:580-353-7777
Practice Address - Fax:580-248-8313
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2008-08-28
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Provider Licenses
StateLicense IDTaxonomies
OK18448207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK700071Medicare PIN