Provider Demographics
NPI:1295773711
Name:SANFORD, CHARLES DAVID (PA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DAVID
Last Name:SANFORD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 S CONGRESS AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-4746
Mailing Address - Country:US
Mailing Address - Phone:561-967-6500
Mailing Address - Fax:561-433-4175
Practice Address - Street 1:4801 S CONGRESS AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-4746
Practice Address - Country:US
Practice Address - Phone:561-967-6500
Practice Address - Fax:561-433-4175
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 3377363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE0990ZMedicare ID - Type Unspecified