Healthcare Provider Details

I. General information

NPI: 1063538544
Provider Name (Legal Business Name): MICHAEL SANDERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 10/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5495 S RAINBOW BLVD STE 101
LAS VEGAS NV
89118-1872
US

IV. Provider business mailing address

PO BOX 30077
SALT LAKE CITY UT
84130-0077
US

V. Phone/Fax

Practice location:
  • Phone: 702-228-0031
  • Fax: 702-228-7253
Mailing address:
  • Phone: 702-477-0772
  • Fax: 702-477-0486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number4301100083
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number16433
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: