Provider Demographics
NPI:1235665225
Name:AGUINALDO, JEREMY (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:AGUINALDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JEREMY
Other - Middle Name:
Other - Last Name:AGUINALDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, MPH, CPH
Mailing Address - Street 1:180 EMERY HWY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3656
Mailing Address - Country:US
Mailing Address - Phone:478-464-0612
Mailing Address - Fax:478-464-0002
Practice Address - Street 1:720 WESTVIEW DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1458
Practice Address - Country:US
Practice Address - Phone:404-752-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
GA80804390200000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003259332CMedicaid