MEDICARE: GINA M DIEUDONNE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	41750	TN

General Provider Information

NPI Number	:	1427030063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA M DIEUDONNE MD

Provider Business Mailing Address
First Line	:	1636 E MAIN STREET
Second Line	:
City	:	HUMBOLDT
State	:	TN
Zip	:	38343-2922
Country	:	US
Telephone Number	:	731-784-7833
Fax Number	:	731-784-7856

Provider Business Practice Location Address
First Line	:	1636 E MAIN ST
Second Line	:
City	:	HUMBOLDT
State	:	TN
Zip	:	38343-2904
Country	:	US
Telephone Number	:	731-784-7833
Fax Number	:	731-784-7856

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2005
Last Update Date	:	08/29/2017

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