Provider Demographics
NPI:1194835207
Name:PICKETT, ALTON W (MD)
Entity Type:Individual
Prefix:MR
First Name:ALTON
Middle Name:W
Last Name:PICKETT
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 1:437 PARK AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087
Mailing Address - Country:US
Mailing Address - Phone:615-444-5102
Mailing Address - Fax:615-443-7390
Practice Address - Street 1:437 PARK AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087
Practice Address - Country:US
Practice Address - Phone:615-444-5102
Practice Address - Fax:615-443-7390
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8162207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000703OtherBCBST
2003231OtherBCS T
3161960Medicare ID - Type Unspecified
2000703OtherBCBST