Provider Demographics
NPI:1679548366
Name:SAWTELLE, JOHN L (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:SAWTELLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 PARK ST
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:TX
Mailing Address - Zip Code:75163-6060
Mailing Address - Country:US
Mailing Address - Phone:903-778-2942
Mailing Address - Fax:903-778-4534
Practice Address - Street 1:218 PARK ST
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:TX
Practice Address - Zip Code:75163-6060
Practice Address - Country:US
Practice Address - Phone:903-778-2942
Practice Address - Fax:903-778-4534
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0063207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S3138OtherBCBS
TX752616977073OtherTRICARE
TXTINOtherTRICARE
TX121503005Medicaid
TX124499OtherSUPERIOR HEALTH - CHIPS
TX752616977073OtherTRICARE
TXP00228099Medicare PIN
TX121503005Medicaid