Provider Demographics
NPI:1730273079
Name:TISDALE, DETRA MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:DETRA
Middle Name:MICHELLE
Last Name:TISDALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 N HOUSTON LEVEE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1144 N HOUSTON LEVEE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7145
Practice Address - Country:US
Practice Address - Phone:901-382-2044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053713207R00000X
LAMD202661207R00000X
TN46435207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06837219Medicaid
LA1369047Medicaid
GAI13259Medicare UPIN
LA1369047Medicaid
LA4N625Medicare PIN