Healthcare Provider Details

I. General information

NPI: 1982798047
Provider Name (Legal Business Name): JOSE M THECKEDATH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 PALMYRA RD
ALBANY GA
31701-1574
US

IV. Provider business mailing address

1911 PALMYRA RD
ALBANY GA
31701-1574
US

V. Phone/Fax

Practice location:
  • Phone: 229-446-7227
  • Fax: 229-420-4365
Mailing address:
  • Phone: 229-446-7227
  • Fax: 229-420-4365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberGA45992
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: