Provider Demographics
NPI:1558391193
Name:DIFULCO, THOMAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:DIFULCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1462 MONTREAL RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6929
Mailing Address - Country:US
Mailing Address - Phone:770-938-9761
Mailing Address - Fax:770-938-6509
Practice Address - Street 1:1462 MONTREAL RD
Practice Address - Street 2:SUITE 303
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6929
Practice Address - Country:US
Practice Address - Phone:770-938-9761
Practice Address - Fax:770-938-6509
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA18215207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000119061GMedicaid
GA$$$$$$$$$GMedicare PIN
GA000119061GMedicaid