=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891852521
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT J SANSOM M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 05/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4351 MCCANN ROAD
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-295-1680
-----------------------------------------------------
Fax | 903-295-1690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O BOX 5608
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-295-1680
-----------------------------------------------------
Fax | 903-295-1690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | E5923
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------