Provider Demographics
NPI:1407903362
Name:MANTLE, SARAH MARSHALL (MD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:MARSHALL
Last Name:MANTLE
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 1:200 GLEAVES ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-2154
Mailing Address - Country:US
Mailing Address - Phone:615-851-7865
Mailing Address - Fax:615-851-7853
Practice Address - Street 1:200 GLEAVES ST
Practice Address - Street 2:SUITE A
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-2154
Practice Address - Country:US
Practice Address - Phone:615-851-7865
Practice Address - Fax:615-851-7853
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45131208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1514044Medicaid