Healthcare Provider Details

I. General information

NPI: 1639179708
Provider Name (Legal Business Name): MITCHELL DANE MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7650 DANNAHER DR
POWELL TN
37849-4065
US

IV. Provider business mailing address

900 E HILL AVE STE 230
KNOXVILLE TN
37915-2565
US

V. Phone/Fax

Practice location:
  • Phone: 865-637-9330
  • Fax: 865-512-6748
Mailing address:
  • Phone: 865-862-0998
  • Fax: 865-544-1861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD0000033814
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: