Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 036.131054 | IL |
Y | 207Q00000X | Family Doctor | K9653 | TX |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 036.131054 | IL |
N | 207QG0300X | Family Doctor - Geriatric Medicine | K9653 | TX |
N | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | 036.131054 | IL |
N | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | K8653 | TX |
NPI | 1770544389 |
---|---|
Provider Name | Mark Allen Sanders |
First Address | Fort Worth, TX 76107-2718 |
Second Address | Fort Worth, TX 76107-2718 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2006 |
Last Update Date | 24/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
080186304 | RAILROAD MEDICARE PIN (01) | TX |
151887001 | (05) | TX |
151887003 | (05) | TX |
151887004 | (05) | TX |
8B2215 | BCBS (01) | TX |
H64931 | (02) | TX |