Provider Demographics
NPI:1083632251
Name:WHEATLEY, KEVIN J (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:WHEATLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 SUMMAR DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3915
Mailing Address - Country:US
Mailing Address - Phone:731-423-1932
Mailing Address - Fax:731-410-0367
Practice Address - Street 1:294 SUMMAR DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3915
Practice Address - Country:US
Practice Address - Phone:731-423-1932
Practice Address - Fax:731-410-0367
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3070786Medicaid
P00264255OtherRAILROAD MEDICARE
TN33916OtherTLC
TN4101274OtherBLUE CROSS BLUE SHIELD
TN4101274OtherBLUE CROSS BLUE SHIELD
TN33916OtherTLC