Healthcare Provider Details

I. General information

NPI: 1174567135
Provider Name (Legal Business Name): RENE MARC HUBERDEAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CLARK-HOLDER CLINIC, P.A. 303 SMITH STREET
LAGRANGE GA
30240
US

IV. Provider business mailing address

CLARK-HOLDER CLINIC, P.A. 303 SMITH STREET
LAGRANGE GA
30240
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-8831
  • Fax: 706-812-4091
Mailing address:
  • Phone: 706-882-8831
  • Fax: 706-812-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number23609
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: