Healthcare Provider Details

I. General information

NPI: 1962106401
Provider Name (Legal Business Name): ADAM SANDERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 08/31/2025
Certification Date: 08/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E. APPLE ST., 6TH FLOOR MAGNOLIA
DAYTON OH
45409
US

IV. Provider business mailing address

30 E. APPLE ST., 6TH FLOOR MAGNOLIA
DAYTON OH
45409
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9926
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0102209168
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: