Basic Information
| Provider Information | |||||||||
| NPI: | 1063407880 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANFORD | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5220 BELFORT RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044463451 | ||||||||
| FaxNumber: | 9044463013 | ||||||||
| Practice Location | |||||||||
| Address1: | 5220 BELFORT RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044463451 | ||||||||
| FaxNumber: | 9044463013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 01/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9202171 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163WW0000X | ARNP 9202171 | FL | N | Nursing Service Providers | Registered Nurse | Wound Care |
ID Information
| ID | Type | State | Issuer | Description | 306547200 | 05 | FL | MEDICAID | P00809977 | 01 | FL | RR MCR ATTACHED TO GRP# CJ8845 | OTHER | Y135U | 01 | FL | BCBS | OTHER |