Basic Information
| Provider Information | |||||||||
| NPI: | 1326022039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DATTILO | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | BARTHOLOMEAU | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53 CENTURY BLVD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372143693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153466213 | ||||||||
| FaxNumber: | 6153466225 | ||||||||
| Practice Location | |||||||||
| Address1: | 4230 HARDING PIKE STE 525 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372052075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153851547 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 04/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 36524 | TN | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 205177 | MA | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | Q007288 | 05 | TN | MEDICAID |