1285795831 NPI number — MRS. JUDIE A. DUMELOD PT, CKTP, IMC, C/NDT

Table of content: MRS. JUDIE A. DUMELOD PT, CKTP, IMC, C/NDT (NPI 1285795831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285795831 NPI number — MRS. JUDIE A. DUMELOD PT, CKTP, IMC, C/NDT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUMELOD
Provider First Name:
JUDIE
Provider Middle Name:
A.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT, CKTP, IMC, C/NDT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285795831
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 ASHVILLE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31210-1669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-474-4035
Provider Business Mailing Address Fax Number:
478-474-7713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3351 NORTHSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31210-2587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-474-4035
Provider Business Practice Location Address Fax Number:
478-474-7713
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  002435 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 537484753A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 306817636A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 813105927A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 193449608B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000760702B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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