Healthcare Provider Details

I. General information

NPI: 1184884793
Provider Name (Legal Business Name): ADDIS DANIEL WINDHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 GARLAND BRISTOL RD
SAUTEE GA
30571-2703
US

IV. Provider business mailing address

253 GARLAND BRISTOL ROAD
SAUTEE GA
30571-2703
US

V. Phone/Fax

Practice location:
  • Phone: 706-878-2664
  • Fax: 706-878-2664
Mailing address:
  • Phone: 706-878-2664
  • Fax: 706-878-2664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number013810
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: