Provider Demographics
NPI:1205323433
Name:MICHAEL, CAMERON (DO)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:MICHAEL
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 1:700 W FOREST AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3940
Mailing Address - Country:US
Mailing Address - Phone:315-419-4907
Mailing Address - Fax:731-541-9485
Practice Address - Street 1:700 W FOREST AVE STE 200
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3940
Practice Address - Country:US
Practice Address - Phone:315-419-4907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN47852084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program