Provider Demographics
NPI:1205824497
Name:REDD, DOUGLAS C (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:C
Last Name:REDD
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 1:5505 PEACHTREE DUNWOODY RD STE 370
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1713
Mailing Address - Country:US
Mailing Address - Phone:770-538-1772
Mailing Address - Fax:770-538-1773
Practice Address - Street 1:5505 PEACHTREE DUNWOODY RD STE 370
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1713
Practice Address - Country:US
Practice Address - Phone:770-538-1772
Practice Address - Fax:770-538-1773
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA324632085R0204X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000755972QMedicaid
GA1609510OtherCIGNA
GACA9328OtherMEDICARE-DMERC GROUP
GA000755972LMedicaid
GA1460074OtherCOVENTRY
GA1609510OtherCIGNA
GA1460074OtherCOVENTRY