Healthcare Provider Details

I. General information

NPI: 1902415383
Provider Name (Legal Business Name): MR. LANARD DONTE SANDERLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5242 SYLVESTER ST
PHILADELPHIA PA
19124-1816
US

IV. Provider business mailing address

5242 SYLVESTER ST
PHILADELPHIA PA
19124-1816
US

V. Phone/Fax

Practice location:
  • Phone: 267-582-6571
  • Fax:
Mailing address:
  • Phone: 267-582-6571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number29434224
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: