Provider Demographics
NPI:1740419340
Name:SEQUOYAH CARE PLLC
Entity Type:Organization
Organization Name:SEQUOYAH CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADOLPHUS
Authorized Official - Middle Name:V
Authorized Official - Last Name:GIST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-216-9511
Mailing Address - Street 1:PO BOX 851438
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75185-1438
Mailing Address - Country:US
Mailing Address - Phone:972-216-9511
Mailing Address - Fax:972-216-9580
Practice Address - Street 1:828 KIRKWOOD DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-2208
Practice Address - Country:US
Practice Address - Phone:972-216-9511
Practice Address - Fax:972-216-9580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-06
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A5058OtherMEDICARE GROUP
TX168406007Medicaid