Provider Demographics
NPI:1033184767
Name:RHEUDASIL, J. MARK (MD)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:MARK
Last Name:RHEUDASIL
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 1:1838 AMERICAN WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6611
Mailing Address - Country:US
Mailing Address - Phone:770-995-7622
Mailing Address - Fax:770-995-7854
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 675
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1731
Practice Address - Country:US
Practice Address - Phone:678-843-5400
Practice Address - Fax:678-843-5449
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0269262085R0202X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000635302Medicaid
GA000635302QMedicaid
GA000635302SMedicaid
GA000635302KMedicaid
GA000635302LMedicaid
GA000635302MMedicaid
GA000635302OMedicaid
GA000635302PMedicaid
GA000635302JMedicaid
GA000635302NMedicaid
GA000635302RMedicaid
GAE10529Medicare UPIN
GA000635302MMedicaid
GA000635302PMedicaid