Provider Demographics
NPI:1831658632
Name:HYDE, ETHAN ALEXANDER
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:ALEXANDER
Last Name:HYDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 MALLORY LN STE 100
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-8230
Mailing Address - Country:US
Mailing Address - Phone:615-814-0885
Mailing Address - Fax:615-814-0056
Practice Address - Street 1:127 CRESTVIEW PARK DR STE 207
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2856
Practice Address - Country:US
Practice Address - Phone:158-140-8856
Practice Address - Fax:615-814-0056
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN926213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty