Provider Demographics
NPI:1396025060
Name:TIRADO GONZALEZ, MARIANTONIETA (MD)
Entity Type:Individual
Prefix:
First Name:MARIANTONIETA
Middle Name:
Last Name:TIRADO GONZALEZ
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 1:1407 UNION AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3641
Mailing Address - Country:US
Mailing Address - Phone:901-866-8003
Mailing Address - Fax:901-302-2003
Practice Address - Street 1:930 MADISON AVE STE 890
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3413
Practice Address - Country:US
Practice Address - Phone:901-866-8834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019025553207ND0900X, 207ZD0900X
TN60822207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology