Provider Demographics
NPI:1285661207
Name:SAWYER, DAVID M
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:SAWYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 207158
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7158
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:510 FREEPORT AVE NW
Practice Address - Street 2:SUITE C
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-3002
Practice Address - Country:US
Practice Address - Phone:763-441-3431
Practice Address - Fax:763-441-4512
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN152W00000X152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN698523800Medicaid
MN9801057PCOtherMEDICA
MNT39923Medicare UPIN
MN698523800Medicaid