Healthcare Provider Details

I. General information

NPI: 1154907061
Provider Name (Legal Business Name): GARRETT D CUDMORE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45465 FIFTH AVE
CALLAHAN FL
32011-3901
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-879-4544
  • Fax: 904-390-7472
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS21394
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: