Provider Demographics
NPI:1528053857
Name:SANFORD, CLYDE FAGG III (MD)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:FAGG
Last Name:SANFORD
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:703 S FLEISHEL AVE
Practice Address - Street 2:STE 4000
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2015
Practice Address - Country:US
Practice Address - Phone:903-606-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9970207RC0000X, 207RI0011X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128834206Medicaid
TX4538099OtherAETNA
TX038665009OtherUNITED HEALTHCARE
TX128834202Medicaid
TX089421JOtherBCBS
TX752616977007OtherTRICARE
TX4538099OtherAETNA
TX060048900Medicare UPIN
D69058Medicare UPIN