Healthcare Provider Details

I. General information

NPI: 1982679775
Provider Name (Legal Business Name): EARLE GLENN SANFORD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 N 2ND ST
CLINTON MO
64735-1192
US

IV. Provider business mailing address

1602 N 2ND ST
CLINTON MO
64735-1192
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-8171
  • Fax:
Mailing address:
  • Phone: 660-885-8171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number1065725A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number20730
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number734054
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2011001499
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: