Provider Demographics
NPI:1467651232
Name:SANDERSON, GARY R (DO)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 N 700 E
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2448
Mailing Address - Country:US
Mailing Address - Phone:801-785-5785
Mailing Address - Fax:
Practice Address - Street 1:1034 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3380
Practice Address - Country:US
Practice Address - Phone:801-373-7850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4645207P00000X
UT6949058-1204207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ117371Medicare PIN
UT000002330Medicare PIN