Provider Demographics
NPI:1023084001
Name:LITTELL, MICHAEL DEAN (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DEAN
Last Name:LITTELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708A N RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-2073
Mailing Address - Country:US
Mailing Address - Phone:615-325-5760
Mailing Address - Fax:
Practice Address - Street 1:700 S BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1625
Practice Address - Country:US
Practice Address - Phone:615-325-3100
Practice Address - Fax:615-325-0076
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO 711207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3301754Medicaid
TN3301754Medicare ID - Type Unspecified
TN3301754Medicaid