Provider Demographics
NPI:1861582413
Name:SANDERSON, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-1915
Mailing Address - Country:US
Mailing Address - Phone:860-223-7900
Mailing Address - Fax:860-826-7161
Practice Address - Street 1:198 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-1915
Practice Address - Country:US
Practice Address - Phone:860-223-7900
Practice Address - Fax:860-826-7161
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001298156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0138150001Medicare ID - Type Unspecified