Individual
DAISY TAN ANTIQUE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
708 W FOREST AVE, JACKSON, TN 38301-3901
(731) 660-8759
(731) 660-8739
Mailing address
1804 HIGHWAY 45 BYP, SUITE 604, JACKSON, TN 38305-4436
(731) 660-8759
(731) 660-8739
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
39516
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3337042
—
TN
01
—
4118140
BCBS
—
01
—
P00364407
RR MEDICARE
—
Enumeration date
03/02/2006
Last updated
12/11/2007
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