Healthcare Provider Details

I. General information

NPI: 1114115623
Provider Name (Legal Business Name): NEAL RAY SANDERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 TERRACE DR
MARION VA
24354-4392
US

IV. Provider business mailing address

2308 AVONDALE DR
JOHNSON CITY TN
37604-2403
US

V. Phone/Fax

Practice location:
  • Phone: 276-783-2511
  • Fax:
Mailing address:
  • Phone: 423-282-6153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101047994
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-005636
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: