Provider Demographics
NPI:1154907061
Name:CUDMORE, GARRETT D (DO)
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:D
Last Name:CUDMORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:45465 FIFTH AVE
Practice Address - Street 2:
Practice Address - City:CALLAHAN
Practice Address - State:FL
Practice Address - Zip Code:32011-3901
Practice Address - Country:US
Practice Address - Phone:904-879-4544
Practice Address - Fax:904-390-7472
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS21394207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine