Provider Demographics
NPI:1447227939
Name:ANTIQUE, DAISY TAN (MD)
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:TAN
Last Name:ANTIQUE
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 1:1804 HIGHWAY 45 BYP
Mailing Address - Street 2:SUITE 604
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4436
Mailing Address - Country:US
Mailing Address - Phone:731-660-8759
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:708 W FOREST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3901
Practice Address - Country:US
Practice Address - Phone:731-660-8759
Practice Address - Fax:731-660-8739
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39516207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00364407OtherRR MEDICARE
TN3337042Medicaid
4118140OtherBCBS
TN3337042Medicaid
TN3337042Medicare ID - Type UnspecifiedJMCGH HOSPITALIST