Provider Demographics
NPI:1548244817
Name:STILLWAGON, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:STILLWAGON
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 116470
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6470
Mailing Address - Country:US
Mailing Address - Phone:404-320-1550
Mailing Address - Fax:404-728-1081
Practice Address - Street 1:698 DULUTH HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7645
Practice Address - Country:US
Practice Address - Phone:770-962-8888
Practice Address - Fax:770-963-7447
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035774174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000582524HMedicaid
GA000582524JMedicaid
GAE35817Medicare UPIN
GA000582524HMedicaid
GA000582524JMedicaid