Provider Demographics
NPI:1891100814
Name:SASTUN FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:SASTUN FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/COO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:505-469-0516
Mailing Address - Street 1:2019 GALISTEO ST
Mailing Address - Street 2:SUITE N9A
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2143
Mailing Address - Country:US
Mailing Address - Phone:505-988-1930
Mailing Address - Fax:505-982-9931
Practice Address - Street 1:2019 GALISTEO ST
Practice Address - Street 2:SUITE N9A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2143
Practice Address - Country:US
Practice Address - Phone:505-988-1930
Practice Address - Fax:505-982-9931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-27
Last Update Date:2016-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty