Healthcare Provider Details

I. General information

NPI: 1427080043
Provider Name (Legal Business Name): KENNETH WAYNE SANDERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8711 LINE AVE
SHREVEPORT LA
71106-6813
US

IV. Provider business mailing address

1811 E BERT KOUNS INDUSTRIAL LOOP SUITE 160
SHREVEPORT LA
71105-5740
US

V. Phone/Fax

Practice location:
  • Phone: 318-698-8711
  • Fax: 318-988-6766
Mailing address:
  • Phone: 318-212-3223
  • Fax: 318-212-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number022757
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: