Provider Demographics
NPI:1538127261
Name:WEICHBRODT, GARY D (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:WEICHBRODT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 CONCORD RD SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-4375
Mailing Address - Country:US
Mailing Address - Phone:770-433-2821
Mailing Address - Fax:770-433-2823
Practice Address - Street 1:1330 CONCORD RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-4375
Practice Address - Country:US
Practice Address - Phone:770-433-2821
Practice Address - Fax:770-433-2823
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0311522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00371236AMedicaid
GA00371236AMedicaid