Provider Demographics
NPI:1700142619
Name:CROSS, STEPHEN DANIEL (DPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:DANIEL
Last Name:CROSS
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20029 ALBERTA ST.
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:TN
Mailing Address - Zip Code:37841
Mailing Address - Country:US
Mailing Address - Phone:423-569-8652
Mailing Address - Fax:423-569-4080
Practice Address - Street 1:20029 ALBERTA ST.
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:TN
Practice Address - Zip Code:37841
Practice Address - Country:US
Practice Address - Phone:423-569-8652
Practice Address - Fax:423-569-4080
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000000469183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452816Medicaid
TNC08486034Medicare UPIN