1568526051 NPI number — DR. LOYD WILLIAM WITHERSPOON JR. DPM

Table of content: DR. LOYD WILLIAM WITHERSPOON JR. DPM (NPI 1568526051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568526051 NPI number — DR. LOYD WILLIAM WITHERSPOON JR. DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITHERSPOON
Provider First Name:
LOYD
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568526051
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 W ESPLANADE AVE
Provider Second Line Business Mailing Address:
PMB 235
Provider Business Mailing Address City Name:
METAIRIE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70006-2551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-779-8120
Provider Business Mailing Address Fax Number:
504-779-9741

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 GUNBARREL RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37421-7174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-499-6488
Provider Business Practice Location Address Fax Number:
423-855-4100
Provider Enumeration Date:
12/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  DPM380 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3353790 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480035339 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000776058A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4047259 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 412064222001 . This is a "TRICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: DA2202 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: TN0101 . This is a "UHC OF RIVER VALLEY" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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