Healthcare Provider Details

I. General information

NPI: 1902977002
Provider Name (Legal Business Name): CLINTON CHARLES SANFORD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2006
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 FAIRVIEW ST
SILVERTON OR
97381-1916
US

IV. Provider business mailing address

333 FAIRVIEW ST.
SILVERTON OR
97381
US

V. Phone/Fax

Practice location:
  • Phone: 503-873-2770
  • Fax: 503-873-2735
Mailing address:
  • Phone: 503-873-2770
  • Fax: 503-873-2735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10096
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: