MEDICARE: DR. TERRY H. SANDERSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	0-536	ID

General Provider Information

NPI Number	:	1427099258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRY H. SANDERSON O.D.

Provider Business Mailing Address
First Line	:	380 S 3RD W
Second Line	:
City	:	SODA SPRINGS
State	:	ID
Zip	:	83276-1559
Country	:	US
Telephone Number	:	208-547-2114
Fax Number	:

Provider Business Practice Location Address
First Line	:	380 S 3RD W
Second Line	:
City	:	SODA SPRINGS
State	:	ID
Zip	:	83276-1559
Country	:	US
Telephone Number	:	208-547-2114
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2006
Last Update Date	:	01/09/2008

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