Provider Demographics
NPI:1134255078
Name:DUNAVANT, ROBERT WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WAYNE
Last Name:DUNAVANT
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 1:610 NUCKOLLS RD
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-1532
Mailing Address - Country:US
Mailing Address - Phone:731-658-7111
Mailing Address - Fax:731-658-4328
Practice Address - Street 1:610 NUCKOLLS RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1532
Practice Address - Country:US
Practice Address - Phone:731-658-7111
Practice Address - Fax:731-658-4328
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD8754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3173148Medicaid
TN080168230OtherMEDICARE RAILROAD
TN3141919OtherBLUE CROSS BLUE SHIELD
TN3141919OtherBLUE CROSS BLUE SHIELD
TNB03576Medicare UPIN