Provider Demographics
NPI:1356336119
Name:ENGBRETSON, JOHN W (MD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:ENGBRETSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 PERKINS EXT
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-3808
Mailing Address - Country:US
Mailing Address - Phone:901-888-2646
Mailing Address - Fax:901-888-2647
Practice Address - Street 1:452 PERKINS EXT
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-3808
Practice Address - Country:US
Practice Address - Phone:901-888-2646
Practice Address - Fax:901-888-2647
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42169207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441917Medicaid
FL267535800Medicaid
FL267535800Medicaid