Provider Demographics
NPI:1083644199
Name:COLDITZ, RICHARD B (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:B
Last Name:COLDITZ
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 1:150 HENRY BURSON DR., STE. # 215
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117
Mailing Address - Country:US
Mailing Address - Phone:770-214-2121
Mailing Address - Fax:770-214-2124
Practice Address - Street 1:150 HENRY BURSON DR., STE. # 215
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117
Practice Address - Country:US
Practice Address - Phone:770-214-2121
Practice Address - Fax:770-214-2124
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010893207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000009215BMedicaid
GA000009215BMedicaid
GAD29159Medicare UPIN