Provider Demographics
NPI:1376747881
Name:JALIU, BOGDAN CRISTIAN (MD)
Entity Type:Individual
Prefix:
First Name:BOGDAN
Middle Name:CRISTIAN
Last Name:JALIU
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 1:2142 W BROAD ST
Mailing Address - Street 2:BLDG 100 STE 200
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3506
Mailing Address - Country:US
Mailing Address - Phone:706-548-6881
Mailing Address - Fax:706-546-0821
Practice Address - Street 1:2142 W BROAD ST
Practice Address - Street 2:BLDG 100 STE 200
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3506
Practice Address - Country:US
Practice Address - Phone:706-548-6881
Practice Address - Fax:706-546-0821
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA650112081P2900X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003106340AMedicaid