Provider Demographics
NPI:1841234424
Name:SANDBERG, JOHN ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:SANDBERG
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:PO BOX 2065
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98111-2065
Mailing Address - Country:US
Mailing Address - Phone:888-828-3195
Mailing Address - Fax:
Practice Address - Street 1:2700 SE STRATUS AVE
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6255
Practice Address - Country:US
Practice Address - Phone:503-472-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11009207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D86804OtherGROUP HEALTH
CAXPY186307Medicaid
67676OtherWA L & I
JM9421OtherPACC
OR197335Medicaid
D86804OtherPROVIDENCE
WA8351447Medicaid
D86804OtherPROVIDENCE
JM9421OtherPACC