Provider Demographics
NPI:1194744524
Name:BLEDSOE, TOMMY D (MD)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:D
Last Name:BLEDSOE
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 1:800 GI MADDOX PKWY
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705-4008
Mailing Address - Country:US
Mailing Address - Phone:706-695-1992
Mailing Address - Fax:866-348-6516
Practice Address - Street 1:800 GI MADDOX PKWY
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-4008
Practice Address - Country:US
Practice Address - Phone:706-695-1992
Practice Address - Fax:866-348-6516
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA041730207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1001399OtherWELLCARE
GA02076817OtherAMERIGROUP
GAP01366671OtherRR MEDICARE
GA02076817OtherAMERIGROUP
GAF96848Medicare UPIN
GA1001399OtherWELLCARE