Provider Demographics
NPI:1720171796
Name:COUNTESS, JULIE M (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:M
Last Name:COUNTESS
Suffix:
Gender:F
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:PO BOX 1172
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37088-1172
Mailing Address - Country:US
Mailing Address - Phone:615-449-5771
Mailing Address - Fax:615-449-5740
Practice Address - Street 1:107 GLIDEPATH WAY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-4133
Practice Address - Country:US
Practice Address - Phone:615-449-5771
Practice Address - Fax:615-449-5740
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41873207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL37945ZMedicare ID - Type Unspecified
FLI0662Medicare UPIN
TN300335Medicare PIN