MEDICARE: DR. EARLE GLENN SANFORD MD

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	207W00000X	Ophthalmology Physician	1065725A	IN
2	207W00000X	Ophthalmology Physician	20730	NE
3	207W00000X	Ophthalmology Physician	734054	TN
4	207W00000X	Ophthalmology Physician	2011001499	MO

General Provider Information

NPI Number	:	1982679775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EARLE GLENN SANFORD MD

Provider Business Mailing Address
First Line	:	1602 N 2ND ST
Second Line	:
City	:	CLINTON
State	:	MO
Zip	:	64735-1192
Country	:	US
Telephone Number	:	660-885-8171
Fax Number	:

Provider Business Practice Location Address
First Line	:	1602 N 2ND ST
Second Line	:
City	:	CLINTON
State	:	MO
Zip	:	64735-1192
Country	:	US
Telephone Number	:	660-885-8171
Fax Number	:

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

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	10/20/2022

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