Provider Demographics
NPI:1972547198
Name:BUDELL, JOHN WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:BUDELL
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 1:2175 NORTHLAKE PKWY
Mailing Address - Street 2:BLDG 4 ST 142
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:770-496-2929
Mailing Address - Fax:770-496-2930
Practice Address - Street 1:2175 NORTHLAKE PKWY
Practice Address - Street 2:BLDG 4 STE 142
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:770-496-2929
Practice Address - Fax:770-496-2930
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA17369207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11SCGBPMedicare ID - Type Unspecified
D29040Medicare UPIN