Provider Demographics
NPI:1043257074
Name:SANNER, DAVID PAUL (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:PAUL
Last Name:SANNER
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:PO BOX 129
Mailing Address - Street 2:815 ROYALL BLVD STE 3
Mailing Address - City:MALAKOFF
Mailing Address - State:TX
Mailing Address - Zip Code:75148-0129
Mailing Address - Country:US
Mailing Address - Phone:903-489-0101
Mailing Address - Fax:903-489-9136
Practice Address - Street 1:815 E ROYALL BLVD
Practice Address - Street 2:
Practice Address - City:MALAKOFF
Practice Address - State:TX
Practice Address - Zip Code:75148-9255
Practice Address - Country:US
Practice Address - Phone:903-489-0101
Practice Address - Fax:903-489-9136
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0069GPOtherBCBS
TX080169693OtherPALMETTO RAILROAD
TX00911MMedicare ID - Type Unspecified