Healthcare Provider Details

I. General information

NPI: 1912933870
Provider Name (Legal Business Name): JOHN T MADONNA JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W CARTER AVE
BLACKSHEAR GA
31516-1412
US

IV. Provider business mailing address

1506 ALICE ST
WAYCROSS GA
31501-4531
US

V. Phone/Fax

Practice location:
  • Phone: 912-632-8961
  • Fax: 912-632-5000
Mailing address:
  • Phone: 912-285-9994
  • Fax: 912-285-9595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME97383
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number031981
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: