Basic Information
Provider Information | |||||||||
NPI: | 1487033387 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANGOTTI | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 103 W BROADWAY AVE | ||||||||
Address2: |   | ||||||||
City: | MARYVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378014703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8652731752 | ||||||||
FaxNumber: | 8652731755 | ||||||||
Practice Location | |||||||||
Address1: | 463 BMH PHYSICIANS OFFICE BLDG | ||||||||
Address2: |   | ||||||||
City: | MARYVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378045807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8659805100 | ||||||||
FaxNumber: | 8659805105 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2015 | ||||||||
LastUpdateDate: | 02/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 63405 | TN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RC0200X | 63405 | TN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 63405 | TN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.