Provider Demographics
NPI:1508147943
Name:MADISON, TERRIA NICOLE (DPM)
Entity Type:Individual
Prefix:MS
First Name:TERRIA
Middle Name:NICOLE
Last Name:MADISON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FREEDOM WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6258
Mailing Address - Country:US
Mailing Address - Phone:706-733-0188
Mailing Address - Fax:706-823-3983
Practice Address - Street 1:1 FREEDOM WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6258
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:706-823-3983
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001239213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist