Provider Demographics
NPI:1104895762
Name:YUAN, JERRY (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:YUAN
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 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:678-284-4076
Practice Address - Street 1:11459 JOHNS CREEK PKWY
Practice Address - Street 2:SUITE 170
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-3515
Practice Address - Country:US
Practice Address - Phone:678-417-0400
Practice Address - Fax:678-417-0483
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042495208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000722543FMedicaid
2361088OtherAETNA
GAP00617411OtherRAILROAD MEDICARE
30533OtherTRICARE
30533OtherTRICARE
GA511I340018Medicare PIN
GAP00617411OtherRAILROAD MEDICARE
GA000722543FMedicaid
GAG30528Medicare UPIN