Provider Demographics
NPI:1093711186
Name:TEDDER, STEPHEN D (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:D
Last Name:TEDDER
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 1:6001 PROFESSIONAL PKWY
Mailing Address - Street 2:SUITE 2040
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5632
Mailing Address - Country:US
Mailing Address - Phone:678-838-9999
Mailing Address - Fax:678-838-9474
Practice Address - Street 1:6001 PROFESSIONAL PKWY
Practice Address - Street 2:SUITE 2040
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5632
Practice Address - Country:US
Practice Address - Phone:678-838-9999
Practice Address - Fax:678-838-9474
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71025207W00000X
GA049112207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08-01712OtherEVERCARE
GA324017OtherWELLCARE
GAP00239339OtherRAILROAD MEDICARE
GA000719155JMedicaid
GA4299075OtherCIGNA
GA930413OtherBCBS
GA18BDGLGMedicare PIN
GAP00239339OtherRAILROAD MEDICARE
GA5540960001Medicare NSC