Provider Demographics
NPI:1376740977
Name:THREADGILL, MATTHEW ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ANTHONY
Last Name:THREADGILL
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 1:1245 AUGUSTA WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1807
Mailing Address - Country:US
Mailing Address - Phone:706-868-0389
Mailing Address - Fax:706-651-0729
Practice Address - Street 1:1245 AUGUSTA WEST PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1807
Practice Address - Country:US
Practice Address - Phone:706-868-0389
Practice Address - Fax:706-651-0729
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002452208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA286300162AMedicaid
GA064081OtherGA LICENSES
GA002452OtherRESIDENCY TRAINING PERMIT