Provider Demographics
NPI:1053755470
Name:SANDERS, JOHNNY RAY
Entity type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:RAY
Last Name:SANDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 BOWLING GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-3236
Mailing Address - Country:US
Mailing Address - Phone:405-473-7230
Mailing Address - Fax:
Practice Address - Street 1:2632 BOWLING GREEN AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-3236
Practice Address - Country:US
Practice Address - Phone:405-473-7230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor