=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043445091
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAIR JAMES SANDALL DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2009
-----------------------------------------------------
Last Update Date | 08/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1347 N. GREENFIELD RD SUITE 101
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85205-4072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-699-8762
-----------------------------------------------------
Fax | 480-699-8350
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1347 N GREENFIELD RD STE 101
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85205-4072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-382-6619
-----------------------------------------------------
Fax | 866-646-5962
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 0704
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------