Individual
DR. DETRA MICHELLE TISDALE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1144 N HOUSTON LEVEE RD, SUITE 102, CORDOVA, TN 38018-7145
(901) 382-2044
Mailing address
1144 N HOUSTON LEVEE RD, SUITE 102, CORDOVA, TN 38018-7145
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
053713
GA
207R00000X
Internal Medicine Physician
Primary
46435
TN
207R00000X
Internal Medicine Physician
MD202661
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
06837219
—
MS
05
—
1369047
—
LA
Enumeration date
10/03/2006
Last updated
12/06/2010
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