Provider Demographics
NPI:1174517064
Name:SANFORD, JERRY D (DC)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:SANFORD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630-4951
Mailing Address - Country:US
Mailing Address - Phone:409-882-9061
Mailing Address - Fax:409-882-0084
Practice Address - Street 1:1404 W PARK AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630-4951
Practice Address - Country:US
Practice Address - Phone:409-882-9061
Practice Address - Fax:409-882-0084
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7054111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU63443Medicare UPIN
TX605561Medicare ID - Type Unspecified