Provider Demographics
NPI:1881237774
Name:MACLEOD, IAN GORDON
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:GORDON
Last Name:MACLEOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2027 ISLAND HOME BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-2740
Mailing Address - Country:US
Mailing Address - Phone:865-237-3124
Mailing Address - Fax:
Practice Address - Street 1:2648 SEVIERVILLE RD
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-3643
Practice Address - Country:US
Practice Address - Phone:865-984-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7208225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant