Provider Demographics
NPI:1669851697
Name:NETTLOW, DARRELL (MD)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:
Last Name:NETTLOW
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 1:301 FISHER ST
Mailing Address - Street 2:
Mailing Address - City:KEESLER AFB
Mailing Address - State:MS
Mailing Address - Zip Code:39534-2508
Mailing Address - Country:US
Mailing Address - Phone:228-376-3846
Mailing Address - Fax:
Practice Address - Street 1:301 FISHER ST
Practice Address - Street 2:
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534-2508
Practice Address - Country:US
Practice Address - Phone:228-376-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS29134207R00000X, 207RC0200X, 207RP1001X
CAA155909207R00000X, 207RC0200X, 207RP1001X
LA330830207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine