Provider Demographics
NPI:1285841775
Name:WORRELL, SANDRA L (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:WORRELL
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 1:6210 E HIGHWAY 290
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:512-483-9596
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:4100 EVERETT
Practice Address - Street 2:#400
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6147
Practice Address - Country:US
Practice Address - Phone:512-295-1333
Practice Address - Fax:512-295-1335
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125049837390200000X
TXN1497207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198779401Medicaid
TX198779402Medicaid
TXP00681017Medicare PIN
TX8L7139Medicare PIN
TX8L7140Medicare PIN