Provider Demographics
NPI:1427083971
Name:SANDEFUR, MARK V (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:V
Last Name:SANDEFUR
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2550 FLOWOOD DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9303
Mailing Address - Country:US
Mailing Address - Phone:601-933-9521
Mailing Address - Fax:601-933-9525
Practice Address - Street 1:2550 FLOWOOD DR
Practice Address - Street 2:SUITE 400
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9303
Practice Address - Country:US
Practice Address - Phone:601-933-9521
Practice Address - Fax:601-933-9525
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS12154207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0121939Medicaid
MSE44294Medicare UPIN