=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366591711
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA K SANDERS M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 04/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10436 SOUTHWEST HWY STE 1
-----------------------------------------------------
City | CHICAGO RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60415-2284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-952-0109
-----------------------------------------------------
Fax | 708-952-0329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10436 SOUTHWEST HWY STE 1
-----------------------------------------------------
City | CHICAGO RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60415-2284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-873-0088
-----------------------------------------------------
Fax | 708-423-4216
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 036-107420
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------