Basic Information
| Provider Information | |||||||||
| NPI: | 1841439270 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALTAWIL | ||||||||
| FirstName: | JOHNNY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 59002 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379509002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655885121 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1311 DOWELL SPRINGS BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379092454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655885121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2009 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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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 | 207R00000X | 4301090449 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q008673 | 05 | TN | MEDICAID |