Healthcare Provider Details

I. General information

NPI: 1265639249
Provider Name (Legal Business Name): JUAN JULIO GELDRES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 RALPH MCGILL BLVD NE #2613
ATLANTA GA
30312-1149
US

IV. Provider business mailing address

660 RALPH MCGILL BLVD NE #2613
ATLANTA GA
30312-1149
US

V. Phone/Fax

Practice location:
  • Phone: 586-306-5788
  • Fax:
Mailing address:
  • Phone: 586-306-5788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number066492
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: