Provider Demographics
NPI:1306978432
Name:BREWSTER, SALLY HOTARD
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:HOTARD
Last Name:BREWSTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 WHISPERING LN
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-9347
Mailing Address - Country:US
Mailing Address - Phone:985-845-9766
Mailing Address - Fax:
Practice Address - Street 1:5825 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-2408
Practice Address - Country:US
Practice Address - Phone:985-966-5220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023029207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMD023029OtherMEDICAL LICENSE
LA1483290Medicaid
4K542DD21Medicare PIN