Provider Demographics
NPI:1801868666
Name:ALLEN, JOHN WILLIAM JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:ALLEN
Suffix:JR
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 1:1211 UNION AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5480 GOODMAN RD STE 1
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7902
Practice Address - Country:US
Practice Address - Phone:662-874-6507
Practice Address - Fax:662-932-8197
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17289208M00000X, 207R00000X
TN50030208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007099Medicaid
AR199932001Medicaid
MS00124398Medicaid
TNQ007099Medicaid
AR199932001Medicaid
MS320173YR80Medicare PIN