Provider Demographics
NPI:1922026806
Name:HUTTON, THERON L (MD)
Entity Type:Individual
Prefix:
First Name:THERON
Middle Name:L
Last Name:HUTTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 W JAMES CAMPBELL BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4659
Mailing Address - Country:US
Mailing Address - Phone:931-364-5090
Mailing Address - Fax:931-364-5091
Practice Address - Street 1:4696 NASHVILLE HWY
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:TN
Practice Address - Zip Code:37034-2110
Practice Address - Country:US
Practice Address - Phone:931-364-5090
Practice Address - Fax:931-364-5091
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114648207Q00000X
TN49541207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3710089Medicaid
4360245OtherBCBST
4360245OtherBCBST
TN3710089Medicare PIN