Provider Demographics
NPI:1285778225
Name:NETTLES, TAMISCHER B (MD)
Entity type:Individual
Prefix:
First Name:TAMISCHER
Middle Name:B
Last Name:NETTLES
Suffix:
Gender:F
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:PO BOX 759047
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9047
Mailing Address - Country:US
Mailing Address - Phone:804-822-4355
Mailing Address - Fax:804-217-7991
Practice Address - Street 1:10210 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3606
Practice Address - Country:US
Practice Address - Phone:410-902-6776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0068868207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD152037ZDDB - 149619Medicare UPIN
MD152037YVZ - 945LMedicare UPIN