Provider Demographics
NPI:1083652267
Name:FREEMAN, GORDON GLENN (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:GLENN
Last Name:FREEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3891 HIGHWAY 78 W
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-3932
Mailing Address - Country:US
Mailing Address - Phone:770-972-4764
Mailing Address - Fax:770-972-4164
Practice Address - Street 1:3891 HIGHWAY 78 W
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-3932
Practice Address - Country:US
Practice Address - Phone:770-972-4764
Practice Address - Fax:770-972-4164
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52260821-001OtherBLUE CROSS BLUE SHIELD PROVIDER ID
1568628618OtherGROUP NPI
GA4073314OtherAETNA PROVIDER ID
1568628618OtherGROUP NPI
D39900Medicare UPIN