Healthcare Provider Details

I. General information

NPI: 1477598076
Provider Name (Legal Business Name): ID MICRO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W RAVINE RD
KINGSPORT TN
37660-3837
US

IV. Provider business mailing address

130 W RAVINE RD
KINGSPORT TN
37660-3837
US

V. Phone/Fax

Practice location:
  • Phone: 423-915-1126
  • Fax:
Mailing address:
  • Phone: 423-915-1126
  • Fax: 423-915-0635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD38189
License Number StateTN

VIII. Authorized Official

Name: DR. ANTON MAKI JR.
Title or Position: OWNER
Credential: MD
Phone: 423-915-1126