Healthcare Provider Details

I. General information

NPI: 1316904048
Provider Name (Legal Business Name): DWIGHT ANTHONY DISHMON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 WESLEY DR SUITE 153
MEMPHIS TN
38116-6442
US

IV. Provider business mailing address

1975 NONCONNAH BLVD
MEMPHIS TN
38132-2108
US

V. Phone/Fax

Practice location:
  • Phone: 901-763-0200
  • Fax: 901-761-4002
Mailing address:
  • Phone: 901-596-4096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number39198
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number39198
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: