Healthcare Provider Details

I. General information

NPI: 1215670583
Provider Name (Legal Business Name): JON ALEXANDER SANFORD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE STE A601
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

100 MICHIGAN ST NE STE A601
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3570
  • Fax: 616-391-3130
Mailing address:
  • Phone: 616-391-3570
  • Fax: 616-391-3130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5151015836
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: