Provider Demographics
NPI:1427552678
Name:SACKLOW, AUTUMN (MD)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:SACKLOW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 WILLIAMS RD
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-5266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 ACADEMY ST # 10
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-3102
Practice Address - Country:US
Practice Address - Phone:207-764-6310
Practice Address - Fax:207-764-6993
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MEMD27947208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program