Provider Demographics
NPI:1952339723
Name:SANWICK, JEFFREY M (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:SANWICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 AINSWORTH DR
Mailing Address - Street 2:STE 101
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1687
Mailing Address - Country:US
Mailing Address - Phone:928-771-5282
Mailing Address - Fax:928-771-5283
Practice Address - Street 1:811 AINSWORTH DR
Practice Address - Street 2:SUITE 101
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1687
Practice Address - Country:US
Practice Address - Phone:928-771-5282
Practice Address - Fax:928-771-5283
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24728174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ482167Medicaid
AZ340017265OtherRAILROAD MEDICARE
AZAZ0855380OtherBLUE CROSS/BLUE SHIELD
AZH02202Medicare UPIN
AZ482167Medicaid