Healthcare Provider Details

I. General information

NPI: 1306917240
Provider Name (Legal Business Name): KENNETH SANDERS MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 YOUREE DR SUITE 110
SHREVEPORT LA
71104-3661
US

IV. Provider business mailing address

PO BOX 44072
SHREVEPORT LA
71134
US

V. Phone/Fax

Practice location:
  • Phone: 318-861-7533
  • Fax:
Mailing address:
  • Phone: 318-797-5602
  • Fax: 318-797-5600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number022757
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number022757
License Number StateLA

VIII. Authorized Official

Name: DANA LYNN SANDERS
Title or Position: OFFICE MANAGER
Credential: RN
Phone: 318-797-5602