Provider Demographics
NPI:1205029352
Name:SIDDALL, BRIAN DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:SIDDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 371
Mailing Address - Street 2:2251 WEST ELM STREET
Mailing Address - City:WRIGHTSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31096-0371
Mailing Address - Country:US
Mailing Address - Phone:478-864-3448
Mailing Address - Fax:478-864-1288
Practice Address - Street 1:280 E WILLOW CREEK LN
Practice Address - Street 2:
Practice Address - City:MC RAE
Practice Address - State:GA
Practice Address - Zip Code:31055-5128
Practice Address - Country:US
Practice Address - Phone:478-864-3448
Practice Address - Fax:478-864-1288
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023227208D00000X
GA23227261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA23227OtherSTATE LICENSE
GA23227OtherSTATE LICENSE