Healthcare Provider Details

I. General information

NPI: 1679792048
Provider Name (Legal Business Name): JEREMY DREW SANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4370 MEDICAL ARTS DR SUITE 200
FLOWER MOUND TX
75028-1712
US

IV. Provider business mailing address

6101 LONG PRAIRIE RD SUITE 744-281
FLOWER MOUND TX
75028-6221
US

V. Phone/Fax

Practice location:
  • Phone: 972-691-7900
  • Fax: 972-691-7910
Mailing address:
  • Phone: 972-691-7900
  • Fax: 972-691-7910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number26290
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: