1942057179 NPI number — MATILDE JADE ZAO YUN RODGERS PA

Table of content: MATILDE JADE ZAO YUN RODGERS PA (NPI 1942057179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942057179 NPI number — MATILDE JADE ZAO YUN RODGERS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RODGERS
Provider First Name:
MATILDE
Provider Middle Name:
JADE ZAO YUN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RODGERS
Provider Other First Name:
ZAY
Provider Other Middle Name:
JADE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1942057179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3950 AUSTELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30106-1121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-732-4000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3950 AUSTELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30106-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-732-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2024

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: 363A00000X , 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)





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