Provider Demographics
NPI:1558468728
Name:BLACK, JUDSON GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:JUDSON
Middle Name:GREGORY
Last Name:BLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:755 MOUNT VERNON HWY NE STE 430
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4279
Mailing Address - Country:US
Mailing Address - Phone:404-303-9945
Mailing Address - Fax:404-303-8257
Practice Address - Street 1:755 MOUNT VERNON HWY NE STE 430
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-4279
Practice Address - Country:US
Practice Address - Phone:404-303-9945
Practice Address - Fax:404-303-8257
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017131207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58-2532446OtherTAX ID
GA11BDRQCMedicare ID - Type Unspecified
GA58-2532446OtherTAX ID