Provider Demographics
NPI:1063736569
Name:SANFORD, CHANTEL NICOLE (DPM)
Entity type:Individual
Prefix:
First Name:CHANTEL
Middle Name:NICOLE
Last Name:SANFORD
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 LONGMAID DR
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-6241
Mailing Address - Country:US
Mailing Address - Phone:443-213-5900
Mailing Address - Fax:410-871-8721
Practice Address - Street 1:804 LONGMAID DR
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-6241
Practice Address - Country:US
Practice Address - Phone:443-213-5900
Practice Address - Fax:410-871-8721
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-26
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEE1-0000231213EP1101X
DCPO1000122213ES0103X
MD01571213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3109344Medicaid
MD392852Medicare UPIN