Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | MD43116 | TN |
Y | 2080P0208X | Pediatric Infectious Diseases | MD43116 | TN |
NPI | 1093812489 |
---|---|
Provider Name | Dr. Demetrio Rebano Macariola JR. |
First Address | Mountain Home, TN 37684-0699 |
Second Address | Johnson City, TN 37604-6062 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 03/11/2010 |