Provider Demographics
NPI:1912143991
Name:HUMPHREYS, THEOPHILUS JAMES (MD)
Entity Type:Individual
Prefix:
First Name:THEOPHILUS
Middle Name:JAMES
Last Name:HUMPHREYS
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 1:127 STANWORTH GRV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4237
Mailing Address - Country:US
Mailing Address - Phone:731-427-0322
Mailing Address - Fax:
Practice Address - Street 1:164 W UNIVERSITY PKWY STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-1621
Practice Address - Country:US
Practice Address - Phone:731-215-1135
Practice Address - Fax:731-410-6156
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5126207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1511064Medicaid
TNB01639Medicare UPIN
TN3002642Medicare PIN
TN110057277Medicare PIN