Provider Demographics
NPI:1770508525
Name:HUDDLESTON, SAMUEL W IV (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:W
Last Name:HUDDLESTON
Suffix:IV
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 1:2002 BROOKSIDE DRIVE
Mailing Address - Street 2:STE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660
Mailing Address - Country:US
Mailing Address - Phone:423-245-7080
Mailing Address - Fax:423-245-7875
Practice Address - Street 1:2002 BROOKSIDE DRIVE
Practice Address - Street 2:STE 201
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-245-7080
Practice Address - Fax:423-245-7875
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN150292086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
384053OtherANTHEM
15029OtherLIC
5331096OtherAETNA
TN3032417Medicaid
0070707OtherBCBS
0070707OtherBCBS
15029OtherLIC
TN3032417Medicaid