Healthcare Provider Details

I. General information

NPI: 1417134222
Provider Name (Legal Business Name): SUSAN LYNN SANDERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 NW SAMARITAN DR
CORVALLIS OR
97330-3737
US

IV. Provider business mailing address

444 NW ELKS DR
CORVALLIS OR
97330-3745
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-1150
  • Fax: 808-775-9404
Mailing address:
  • Phone: 541-754-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number10607
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD156493
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: