Healthcare Provider Details

I. General information

NPI: 1073604609
Provider Name (Legal Business Name): MARK C SANDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 11/27/2023
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1184 E 80 N
AMERICAN FORK UT
84003-2906
US

IV. Provider business mailing address

1055 N 500 W CREDENTIALING DEPARTMENT
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-763-3885
  • Fax: 801-763-3887
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number187115-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number187115-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number187115-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: