Provider Demographics
NPI:1003857517
Name:MEDFAST 2
Entity Type:Organization
Organization Name:MEDFAST 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:A
Authorized Official - Last Name:KLUG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-285-3157
Mailing Address - Street 1:1405 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4528
Mailing Address - Country:US
Mailing Address - Phone:912-285-3157
Mailing Address - Fax:912-283-2051
Practice Address - Street 1:1405 ALICE ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4528
Practice Address - Country:US
Practice Address - Phone:912-285-3157
Practice Address - Fax:912-283-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031778209800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes209800000XAllopathic & Osteopathic PhysiciansLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD90197Medicare UPIN
GA16BDFGJMedicare ID - Type Unspecified