Provider Demographics
NPI:1306917240
Name:KENNETH SANDERS MD PLLC
Entity type:Organization
Organization Name:KENNETH SANDERS MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:318-797-5602
Mailing Address - Street 1:PO BOX 44072
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71134
Mailing Address - Country:US
Mailing Address - Phone:318-797-5602
Mailing Address - Fax:318-797-5600
Practice Address - Street 1:2800 YOUREE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3661
Practice Address - Country:US
Practice Address - Phone:318-861-7533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022757207YX0905X, 207YS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep MedicineGroup - Multi-Specialty
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5Y181Medicare PIN
G39728Medicare UPIN