Provider Demographics
NPI:1427282763
Name:SANFORD, LORI JACQUEMIN (MD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:JACQUEMIN
Last Name:SANFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E BOYD AVE
Mailing Address - Street 2:STE 209
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-2834
Mailing Address - Country:US
Mailing Address - Phone:317-967-7921
Mailing Address - Fax:
Practice Address - Street 1:300 E BOYD AVE
Practice Address - Street 2:STE 209
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-2834
Practice Address - Country:US
Practice Address - Phone:317-967-7921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-14
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072559A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ2966001OtherMEDICARE
IN201100610AMedicaid
ININ2966001OtherMEDICARE