Tisdale, Detra Michelle

Tisdale, Detra Michelle is an individual health care provider with primary practice located at 1144 N Houston Levee Rd Suite 102, Cordova TN 38018-7145. She recently has only one registered license in Allopathic & Osteopathic Physicians / Internal Medicine, which is considered as her primary health care specialty. Tisdale, Detra Michelle can be contacted via phone (901) 382-2044.

Contact Information

Primary practice address
1144 N Houston Levee Rd Suite 102 Cordova TN 38018-7145
Phone: (901) 382-2044
Fax:
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Internal Medicine 207R00000X 053713 Georgia
Allopathic & Osteopathic Physicians / Internal Medicine 207R00000X MD202661 Louisiana
Allopathic & Osteopathic Physicians / Internal Medicine 207R00000X 46435 Tennessee

Profile Details

NPI number 1730273079
LBN Legal business name Tisdale, Detra Michelle
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date Oct 3rd, 2006
Last updated Dec 6th, 2010 - about 14 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1730273079 NPPES
Mississippi MEDICAID 06837219
Mississippi MEDICAID 1369047

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