Basic Information
| Provider Information | |||||||||
| NPI: | 1801996715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187368757 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187368757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2010 | ||||||||
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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 | 207Q00000X | 21639 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 107116 | 01 | MN | UCAREMN | OTHER | 147662401 | 05 | TX | MEDICAID | 0967679 | 05 | IA | MEDICAID | HP26725 | 01 | MN | HEALTHPARTNERS | OTHER | 0159499 | 05 | WA | MEDICAID | 01-23706 | 01 | MN | MEDICABLC | OTHER | 265283800 | 05 | MN | MEDICAID | 1008797 | 01 | MN | PREFERREDONE | OTHER | 62780SA | 01 | MN | BCBS | OTHER | 41091744413 | 05 | NE | MEDICAID | 01-00797 | 01 | MN | MEDICAFFMG & WRC | OTHER | 13217 | 05 | ND | MEDICAID |