Provider Demographics
NPI:1427099258
Name:SANDERSON, TERRY H (OD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:H
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 S 3RD W
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276-1559
Mailing Address - Country:US
Mailing Address - Phone:208-547-2114
Mailing Address - Fax:
Practice Address - Street 1:380 S 3RD W
Practice Address - Street 2:
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276-1559
Practice Address - Country:US
Practice Address - Phone:208-547-2114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-536152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist