Provider Demographics
NPI:1306836804
Name:BROWN-TISDALE, CHUCKIA NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHUCKIA
Middle Name:NICOLE
Last Name:BROWN-TISDALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11116 MEDICAL CAMPUS RD
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11110 MEDICAL CAMPUS RD STE 143
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6755
Practice Address - Country:US
Practice Address - Phone:301-714-4175
Practice Address - Fax:301-714-4183
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0063718207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD409370400Medicaid
MDM974Medicare PIN