Provider Demographics
NPI:1609112358
Name:JEREMY DREW SANDERSON, MD, PA
Entity type:Organization
Organization Name:JEREMY DREW SANDERSON, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:DREW
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-837-4524
Mailing Address - Street 1:6101 LONG PRAIRIE RD
Mailing Address - Street 2:SUITE 744-281
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-6221
Mailing Address - Country:US
Mailing Address - Phone:972-691-7900
Mailing Address - Fax:972-691-7910
Practice Address - Street 1:4370 MEDICAL ARTS DR
Practice Address - Street 2:SUITE 200
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1712
Practice Address - Country:US
Practice Address - Phone:972-691-7900
Practice Address - Fax:972-691-7910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-28
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2164207YX0007X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty