Provider Demographics
NPI:1023276870
Name:DESHAZER, MITCHELL
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:DESHAZER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N STATE OF FRANKLIN RD
Mailing Address - Street 2:ROOM 2746
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6035
Mailing Address - Country:US
Mailing Address - Phone:423-431-2727
Mailing Address - Fax:423-431-6715
Practice Address - Street 1:400 N STATE OF FRANKLIN RD
Practice Address - Street 2:ROOM 2746
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-431-2727
Practice Address - Fax:423-431-6715
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2058208M00000X, 207R00000X
UT7932447-1205207R00000X
TN51285207RC0200X, 207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01365055OtherRAILROAD MEDICARE
VA1023276870Medicaid
TNQ007623Medicaid
KY7100376940Medicaid
NC1023276870Medicaid
NC1023276870Medicaid