Provider Demographics
NPI:1558362830
Name:BLADUELL, NYDIA M (MD)
Entity Type:Individual
Prefix:DR
First Name:NYDIA
Middle Name:M
Last Name:BLADUELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WHITCHER ST NE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1155
Mailing Address - Country:US
Mailing Address - Phone:770-424-6893
Mailing Address - Fax:770-528-9938
Practice Address - Street 1:55 WHITCHER ST NE
Practice Address - Street 2:SUITE 350
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1155
Practice Address - Country:US
Practice Address - Phone:770-424-6893
Practice Address - Fax:770-528-9938
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038429207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000599057IMedicaid
GA000599057DMedicaid
GA000599057FMedicaid
GA000599057EMedicaid
GA000599057GMedicaid
GA000599057HMedicaid
GA000599057MMedicaid
GA000599057DMedicaid
GAF27556Medicare UPIN
GA000599057MMedicaid