1962578914 NPI number — MARK JOSEPH SANFORD MS, CCC-A

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962578914 NPI number — MARK JOSEPH SANFORD MS, CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANFORD
Provider First Name:
MARK
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, CCC-A
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962578914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 PANORAMIC WAY FL 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALNUT CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94595-1627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-938-8686
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 PANORAMIC WAY FL 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALNUT CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94595-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-938-8686
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237600000X , with the licence number:  AU1138 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 237600000X , with the licence number: HA2506 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AU0011380 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: AU0011380 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HA0025060 . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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