Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 64216 | GA |
N | 207QS0010X | Family Doctor - Sports Medicine | 31037 | AL |
N | 207QS0010X | Family Doctor - Sports Medicine | 64216 | GA |
N | 207QS0010X | Family Doctor - Sports Medicine | 7553 | KS |
NPI | 1265744759 |
---|---|
Provider Name | Jean Robert Ferdinand |
First Address | Mcdonough, GA 30253-8297 |
Second Address | Locust Grove, GA 30248-3513 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2010 |
Last Update Date | 16/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
003111758C | (05) | GA |
12263436 | CAQH (01) |