Provider Demographics
NPI:1336117811
Name:GUILLORY, DALE J (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:J
Last Name:GUILLORY
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 1:39 EAST 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2503
Mailing Address - Country:US
Mailing Address - Phone:931-520-7520
Mailing Address - Fax:931-526-8212
Practice Address - Street 1:39 E 1ST ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2503
Practice Address - Country:US
Practice Address - Phone:931-520-7520
Practice Address - Fax:931-526-8212
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000025569174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3087831Medicare PIN
TNF94506Medicare UPIN