Provider Demographics
NPI:1194951517
Name:JOHN L SAWTELLE DO PA
Entity type:Organization
Organization Name:JOHN L SAWTELLE DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:CPC CMC
Authorized Official - Phone:903-510-1113
Mailing Address - Street 1:218 PARK ST
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:TX
Mailing Address - Zip Code:75163-6060
Mailing Address - Country:US
Mailing Address - Phone:903-778-2942
Mailing Address - Fax:903-778-2537
Practice Address - Street 1:218 PARK ST
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:TX
Practice Address - Zip Code:75163-6060
Practice Address - Country:US
Practice Address - Phone:903-778-2942
Practice Address - Fax:903-778-2537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0063261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care