Provider Demographics
NPI:1639468812
Name:ALTON, TIA M (MD)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:M
Last Name:ALTON
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:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-272-5395
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:150 FRANKFORT RD STE 101
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-7401
Practice Address - Country:US
Practice Address - Phone:502-647-5468
Practice Address - Fax:502-647-7134
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY46839208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program