1558429779 NPI number — DR. JOHN E MOTHERAL D.PH.

Table of content: DR. JOHN E MOTHERAL D.PH. (NPI 1558429779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558429779 NPI number — DR. JOHN E MOTHERAL D.PH.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOTHERAL
Provider First Name:
JOHN
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.PH.
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:
1558429779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2340 CEDAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MC KENZIE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38201-2249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-352-3242
Provider Business Mailing Address Fax Number:
731-352-5860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2340 CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MC KENZIE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38201-2249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-352-3242
Provider Business Practice Location Address Fax Number:
731-352-5860
Provider Enumeration Date:
12/04/2006

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: 183500000X , with the licence number:  0000002625 , 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)





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