Provider Demographics
NPI:1215135025
Name:SWEETWATER PEDIATRICS P.C.
Entity type:Organization
Organization Name:SWEETWATER PEDIATRICS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANDRASHEKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:YESHLUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-362-5500
Mailing Address - Street 1:1204 HILLTOP DR
Mailing Address - Street 2:SUITE#106
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5861
Mailing Address - Country:US
Mailing Address - Phone:307-362-5500
Mailing Address - Fax:307-362-0300
Practice Address - Street 1:1204 HILLTOP DR
Practice Address - Street 2:SUITE#106
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5861
Practice Address - Country:US
Practice Address - Phone:307-362-5500
Practice Address - Fax:307-362-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6946A261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
H98662Medicare UPIN