Provider Demographics
NPI:1316904048
Name:DISHMON, DWIGHT ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:ANTHONY
Last Name:DISHMON
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 1:1975 NONCONNAH BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38132-2108
Mailing Address - Country:US
Mailing Address - Phone:901-596-4096
Mailing Address - Fax:
Practice Address - Street 1:1251 WESLEY DR
Practice Address - Street 2:SUITE 153
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6442
Practice Address - Country:US
Practice Address - Phone:901-763-0200
Practice Address - Fax:901-761-4002
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39198207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3325860Medicaid
AR155106001Medicaid
TN4354768OtherBCBS
TNP01301155OtherRAILROAD MEDICARE
MS07222339Medicaid
TN3325860Medicaid
TN103I062180Medicare PIN