Provider Demographics
NPI:1144303124
Name:SANDERS, CHARLES RICHARD JR (MD)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:RICHARD
Last Name:SANDERS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6161
Mailing Address - Country:US
Mailing Address - Phone:229-228-4130
Mailing Address - Fax:229-226-4690
Practice Address - Street 1:951 S BROAD ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6161
Practice Address - Country:US
Practice Address - Phone:229-228-4130
Practice Address - Fax:229-226-4690
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0116065OtherUNITED HEALTHCARE
GA4711658OtherCIGNA PROVIDER NUMBER
GA00433958CMedicaid
GA11D0266342OtherCLIA LAB NUMBER
GA024373OtherBCBS PROVIDER NUMBER
GAGRP1474OtherMEDICARE GROUP NUMBER
GAE87639Medicare UPIN
GA11D0266342OtherCLIA LAB NUMBER