Provider Demographics
NPI:1114507605
Name:ADDISON, DAVID BRADLEY
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:BRADLEY
Last Name:ADDISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7020 TREE HOUSE WAY
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-7545
Mailing Address - Country:US
Mailing Address - Phone:470-332-5081
Mailing Address - Fax:
Practice Address - Street 1:7020 TREE HOUSE WAY
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-7545
Practice Address - Country:US
Practice Address - Phone:470-332-5081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA02083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine