Provider Demographics
NPI:1699742023
Name:SANDERS, SANDY KENT (MD)
Entity type:Individual
Prefix:
First Name:SANDY
Middle Name:KENT
Last Name:SANDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:FL
Mailing Address - Zip Code:32693-3239
Mailing Address - Country:US
Mailing Address - Phone:352-463-2374
Mailing Address - Fax:352-463-2726
Practice Address - Street 1:1010 NW 8TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-4946
Practice Address - Country:US
Practice Address - Phone:352-376-8211
Practice Address - Fax:352-463-4507
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME12145208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040090400Medicaid