Provider Demographics
NPI:1043451578
Name:RAY W. METTETAL JR., M.D. INC.
Entity Type:Organization
Organization Name:RAY W. METTETAL JR., M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:METTETAL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:423-341-7538
Mailing Address - Street 1:303 E 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-3932
Mailing Address - Country:US
Mailing Address - Phone:423-282-5411
Mailing Address - Fax:423-282-5951
Practice Address - Street 1:329 WESLEY ST STE 4
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1721
Practice Address - Country:US
Practice Address - Phone:423-282-5411
Practice Address - Fax:423-282-5951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 10753261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty