MEDICARE: DR. GORDON MICHAEL DUFFELL 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	174400000X	Specialist	009466	GA

General Provider Information

NPI Number	:	1700152519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GORDON MICHAEL DUFFELL MD

Provider Business Mailing Address
First Line	:	2751 BRECKENRIDGE CT NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30345-4001
Country	:	US
Telephone Number	:	404-636-7622
Fax Number	:

Provider Business Practice Location Address
First Line	:	2751 BRECKENRIDGE CT NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30345-4001
Country	:	US
Telephone Number	:	404-636-7622
Fax Number	:

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

Provider Enumeration Date	:	03/26/2012
Last Update Date	:	03/26/2012

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