Basic Information
| Provider Information | |||||||||
| NPI: | 1477598076 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ID MICRO PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 W RAVINE RD | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239151126 | ||||||||
| FaxNumber: | 4239150635 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 W RAVINE RD | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239151126 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 01/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | MAKI | ||||||||
| AuthorizedOfficialFirstName: | ANTON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4239151126 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | MD38189 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.