Provider Demographics
NPI:1982623591
Name:ANTIQUE, JULIE TAN (MD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:TAN
Last Name:ANTIQUE
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 1:620 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3923
Mailing Address - Country:US
Mailing Address - Phone:731-541-6472
Mailing Address - Fax:731-541-3188
Practice Address - Street 1:620 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3923
Practice Address - Country:US
Practice Address - Phone:731-541-6472
Practice Address - Fax:731-541-3188
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38425207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3326081Medicaid
4097479OtherBCBS
P00179539OtherRR MEDICARE
TNP00181736OtherRR MEDICARE
TN3326089Medicaid
4097479OtherBCBS
TN3326089Medicaid