Provider Demographics
NPI:1215904859
Name:GRODZIN, CHARLES J (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:GRODZIN
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 1:550 PEACHTREE ST NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2212
Mailing Address - Country:US
Mailing Address - Phone:404-686-4411
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2212
Practice Address - Country:US
Practice Address - Phone:404-686-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0226207RP1001X
GA071760207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142057203Medicaid
TX142058002Medicaid
TX142057204Medicaid
TX290013827OtherRR MEDICARE DENTO CO
TX290013828OtherRR MEDICARE DALLAS CO
TX8A2490OtherBCBS
TX142057201Medicaid
TXF53060Medicare UPIN
TX8G6333Medicare ID - Type Unspecified
TX8384K1Medicare ID - Type UnspecifiedDALLAS CO
TX142057203Medicaid
TX290013827OtherRR MEDICARE DENTO CO
TX142057201Medicaid
TX8F5602Medicare PIN
TX8J7491Medicare PIN