Provider Demographics
NPI:1639179708
Name:MARTIN, MITCHELL DANE (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DANE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E HILL AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37915-2565
Mailing Address - Country:US
Mailing Address - Phone:865-862-0998
Mailing Address - Fax:865-544-1861
Practice Address - Street 1:7650 DANNAHER DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-4065
Practice Address - Country:US
Practice Address - Phone:865-637-9330
Practice Address - Fax:865-512-6748
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000033814207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4081810OtherBLUE CROSS BLUE SHIELD
P00099384OtherMEDICARE RAILROAD
TN3850435Medicaid
TN3850435Medicaid
TN3850435Medicare PIN