Provider Demographics
NPI:1699942573
Name:DR. MIKE M SANDY, OPTOMETRIST, LLC
Entity type:Organization
Organization Name:DR. MIKE M SANDY, OPTOMETRIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SANDY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:901-219-3453
Mailing Address - Street 1:8405 SHADY ELM DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-0437
Mailing Address - Country:US
Mailing Address - Phone:901-219-3453
Mailing Address - Fax:
Practice Address - Street 1:3775 HACKS CROSS RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-2302
Practice Address - Country:US
Practice Address - Phone:901-214-0065
Practice Address - Fax:901-214-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-10
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT2015152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty