Provider Demographics
NPI:1245240522
Name:DHALIWAL, AVTAR S (MD)
Entity Type:Individual
Prefix:
First Name:AVTAR
Middle Name:S
Last Name:DHALIWAL
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 1:1416 S ROAN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-7332
Mailing Address - Country:US
Mailing Address - Phone:423-979-6257
Mailing Address - Fax:423-979-6285
Practice Address - Street 1:1416 S ROAN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-7332
Practice Address - Country:US
Practice Address - Phone:423-979-6257
Practice Address - Fax:423-979-6285
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD10146208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B02928Medicare UPIN