Provider Demographics
NPI:1679758866
Name:MARTY K SANNER MD PC
Entity type:Organization
Organization Name:MARTY K SANNER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:K
Authorized Official - Last Name:SANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-353-7777
Mailing Address - Street 1:4202 SW LEE BLVD
Mailing Address - Street 2:BLDG A SUITE 104
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505
Mailing Address - Country:US
Mailing Address - Phone:580-353-7777
Mailing Address - Fax:580-248-8313
Practice Address - Street 1:4202 SW LEE BLVD
Practice Address - Street 2:BLDG A SUITE 104
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:580-353-7777
Practice Address - Fax:580-248-8313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18448207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100101130DMedicaid
OK100101130DMedicaid