Provider Demographics
NPI:1598954125
Name:LOFTISS, CARRIE (MD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:LOFTISS
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 1:3322 W END AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1031
Mailing Address - Country:US
Mailing Address - Phone:615-515-9880
Mailing Address - Fax:605-505-9891
Practice Address - Street 1:1167 S GREEN ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-4900
Practice Address - Country:US
Practice Address - Phone:662-322-7064
Practice Address - Fax:662-775-4244
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57-013094207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04787221Medicaid
MS04787221Medicaid