Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | MD44752 | TN |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | MD44752 | TN |
NPI | 1205948254 |
---|---|
Provider Name | John Douglas Haltom JR. |
First Address | Jackson, TN 38305-2070 |
Second Address | Jackson, TN 38305-2070 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 02/11/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1517709 | (05) | TN |