Provider Demographics
NPI:1376075705
Name:JUDE, DIAMOND (MD)
Entity Type:Individual
Prefix:
First Name:DIAMOND
Middle Name:
Last Name:JUDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIAMOND
Other - Middle Name:
Other - Last Name:ODELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:777 HEMLOCK STREET MSC #104
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-741-7241
Mailing Address - Fax:
Practice Address - Street 1:777 HEMLOCK STREET MSC #104
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-741-7241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA86098207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program