Healthcare Provider Details

I. General information

NPI: 1811986490
Provider Name (Legal Business Name): DAVID THEODORE HAMILOS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 PRINCETON RD STE 202
JOHNSON CITY TN
37601-2063
US

IV. Provider business mailing address

508 PRINCETON RD SUITE 202
JOHNSON CITY TN
37601-2060
US

V. Phone/Fax

Practice location:
  • Phone: 423-926-2741
  • Fax: 423-926-5782
Mailing address:
  • Phone: 423-926-2741
  • Fax: 423-926-5782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000284
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: