Provider Demographics
NPI:1366410599
Name:MEDEIROS, MILTON O (MD)
Entity type:Individual
Prefix:
First Name:MILTON
Middle Name:O
Last Name:MEDEIROS
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 1:3035 N HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3411
Mailing Address - Country:US
Mailing Address - Phone:731-664-0899
Mailing Address - Fax:731-664-0946
Practice Address - Street 1:3035 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3411
Practice Address - Country:US
Practice Address - Phone:731-664-0899
Practice Address - Fax:731-664-0946
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7727174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3827978Medicaid
TN000000034150OtherTLC NO
TNP00242733OtherRAILROAD MEDICARE NO
TN4105401OtherBCBS OF TENNESSEE
TN000000165679OtherUNISON NO
TN000000034150OtherTLC NO
TN3827978Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NO