MEDICARE: DR. TRACIE SHENELLE CALLOWAY-LAWSON DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	P7404	TX
2	208000000X	Pediatrics Physician	E-8026	AR

General Provider Information

NPI Number	:	1629395520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACIE SHENELLE CALLOWAY-LAWSON DO

Provider Business Mailing Address
First Line	:	4503 TEXAS BLVD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-3026
Country	:	US
Telephone Number	:	903-792-4003
Fax Number	:	903-792-2230

Provider Business Practice Location Address
First Line	:	4503 TEXAS BLVD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-3026
Country	:	US
Telephone Number	:	903-792-4003
Fax Number	:	903-792-2230

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2010
Last Update Date	:	04/03/2020

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