Provider Demographics
NPI:1184675332
Name:MOTLEY, TODD (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:MOTLEY
Suffix:
Gender:M
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:PO BOX 2153
Mailing Address - Street 2:DEPT 3252
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-0002
Mailing Address - Country:US
Mailing Address - Phone:901-332-2277
Mailing Address - Fax:901-332-2270
Practice Address - Street 1:1264 WESLEY DR
Practice Address - Street 2:SUITE 201
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6400
Practice Address - Country:US
Practice Address - Phone:901-332-2277
Practice Address - Fax:901-332-2270
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000033846207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3857410Medicaid
MS09015714Medicaid
MS09015714Medicaid
TNH25120Medicare UPIN