Provider Demographics
NPI:1518941608
Name:CARDILLO, DOUGLAS M (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
Last Name:CARDILLO
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 1:201 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2408
Mailing Address - Country:US
Mailing Address - Phone:770-720-5100
Mailing Address - Fax:404-851-6325
Practice Address - Street 1:450 NORTHSIDE CHEROKEE BLVD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8015
Practice Address - Country:US
Practice Address - Phone:770-224-1000
Practice Address - Fax:770-224-2451
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053432207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG53432Medicaid
GA354312478DMedicaid
GA354312478EMedicaid
GA354312478DMedicaid
SCG53432Medicaid
GA354312478EMedicaid