Basic Information
| Provider Information | |||||||||
| NPI: | 1396025060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIRADO GONZALEZ | ||||||||
| FirstName: | MARIANTONIETA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1407 UNION AVE STE 700 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668003 | ||||||||
| FaxNumber: | 9013022003 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 MADISON AVE STE 890 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381033413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668834 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2011 | ||||||||
| LastUpdateDate: | 05/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | 2019025553 | MO | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ZD0900X | 2019025553 | MO | N | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZD0900X | 60822 | TN | Y | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
No ID Information.