Provider Demographics
NPI:1477598076
Name:ID MICRO PLLC
Entity Type:Organization
Organization Name:ID MICRO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTON
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKI
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:423-915-1126
Mailing Address - Street 1:130 W RAVINE RD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3837
Mailing Address - Country:US
Mailing Address - Phone:423-915-1126
Mailing Address - Fax:423-915-0635
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-915-1126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD38189207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F52974Medicare UPIN