Provider Demographics
NPI:1376574863
Name:MUDREY, MICHAEL DAREN (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAREN
Last Name:MUDREY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1332
Mailing Address - Street 2:
Mailing Address - City:MC CAYSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30555-1332
Mailing Address - Country:US
Mailing Address - Phone:706-632-3711
Mailing Address - Fax:
Practice Address - Street 1:3540 COBB PKWY
Practice Address - Street 2:STE 100
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101
Practice Address - Country:US
Practice Address - Phone:706-632-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038564207P00000X
GA38564208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000621398JMedicaid
GA000621398JMedicaid