Provider Demographics
NPI:1275506404
Name:AMONETTE, REX ALLEN (MD)
Entity Type:Individual
Prefix:MR
First Name:REX
Middle Name:ALLEN
Last Name:AMONETTE
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 1:1455 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6727
Mailing Address - Country:US
Mailing Address - Phone:901-726-6655
Mailing Address - Fax:901-726-9056
Practice Address - Street 1:1455 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-6727
Practice Address - Country:US
Practice Address - Phone:901-726-6655
Practice Address - Fax:901-726-9056
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD6594207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Not Answered207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3151813Medicaid
B02373Medicare UPIN
3151814Medicare ID - Type Unspecified