Provider Demographics
NPI:1629493713
Name:SUMIDA, DEDRE (MD)
Entity Type:Individual
Prefix:DR
First Name:DEDRE
Middle Name:
Last Name:SUMIDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DEIDRE
Other - Middle Name:
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2051B HAMILL RD STE 107
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4092
Mailing Address - Country:US
Mailing Address - Phone:423-877-4705
Mailing Address - Fax:423-877-9970
Practice Address - Street 1:2051B HAMILL RD STE 107
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4092
Practice Address - Country:US
Practice Address - Phone:423-877-4705
Practice Address - Fax:423-877-9970
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28047208000000X
CABB4317459208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics