Healthcare Provider Details

I. General information

NPI: 1003857517
Provider Name (Legal Business Name): MEDFAST 2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 ALICE ST
WAYCROSS GA
31501-4528
US

IV. Provider business mailing address

1405 ALICE ST
WAYCROSS GA
31501-4528
US

V. Phone/Fax

Practice location:
  • Phone: 912-285-3157
  • Fax: 912-283-2051
Mailing address:
  • Phone: 912-285-3157
  • Fax: 912-283-2051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number031778
License Number StateGA

VIII. Authorized Official

Name: GERARDO A KLUG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 912-285-3157