Provider Demographics
NPI:1477537470
Name:FORDHAM, DONALD L (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:L
Last Name:FORDHAM
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-0308
Mailing Address - Country:US
Mailing Address - Phone:706-754-8811
Mailing Address - Fax:706-754-8822
Practice Address - Street 1:865 AUSTIN DR
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4513
Practice Address - Country:US
Practice Address - Phone:706-754-8811
Practice Address - Fax:706-754-8822
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044718207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG41162Medicare UPIN
GA08BDPCDMedicare ID - Type Unspecified