Provider Demographics
NPI:1689962524
Name:MIEDEMA, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MIEDEMA
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 1:25 WOODBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38068-1242
Mailing Address - Country:US
Mailing Address - Phone:901-465-6353
Mailing Address - Fax:833-902-3599
Practice Address - Street 1:25 WOODBRIDGE RD STE A
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-1242
Practice Address - Country:US
Practice Address - Phone:901-465-6353
Practice Address - Fax:833-902-3599
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN65449208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN