Healthcare Provider Details

I. General information

NPI: 1851663124
Provider Name (Legal Business Name): DAFFODIL PEDIATRICS AND FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4905 COURTNEY DRIVE
FOREST PARK GA
30297
US

IV. Provider business mailing address

4905 COURTNEY DRIVE
FOREST PARK GA
30297
US

V. Phone/Fax

Practice location:
  • Phone: 404-366-3636
  • Fax: 404-362-0808
Mailing address:
  • Phone: 404-366-3636
  • Fax: 404-362-0808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JON FREDERICK STACHELRODT
Title or Position: CEO
Credential:
Phone: 310-429-8614