1679758866 NPI number — MARTY K SANNER MD PC

Table of content: (NPI 1679758866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679758866 NPI number — MARTY K SANNER MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTY K SANNER MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1679758866
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4202 SW LEE BLVD
Provider Second Line Business Mailing Address:
BLDG A SUITE 104
Provider Business Mailing Address City Name:
LAWTON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-353-7777
Provider Business Mailing Address Fax Number:
580-248-8313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4202 SW LEE BLVD
Provider Second Line Business Practice Location Address:
BLDG A SUITE 104
Provider Business Practice Location Address City Name:
LAWTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-353-7777
Provider Business Practice Location Address Fax Number:
580-248-8313
Provider Enumeration Date:
01/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SANNER
Authorized Official First Name:
MARTY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
580-353-7777

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  18448 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100101130D , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com