Basic Information
| Provider Information | |||||||||
| NPI: | 1932122868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | VAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 POYDRAS ST | ||||||||
| Address2: | SUITE 1640 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701121221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044121835 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2021 PERDIDO ST | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701121352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049033000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 10/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 009854 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207R00000X | 009854 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 009854 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1121851 | 05 | LA | MEDICAID |