Provider Demographics
NPI:1588646012
Name:CRADDOCK, GARNET R JR (MD)
Entity Type:Individual
Prefix:
First Name:GARNET
Middle Name:R
Last Name:CRADDOCK
Suffix:JR
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 1:2959 SHARPSBURG MCCULLUM RD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2297
Mailing Address - Country:US
Mailing Address - Phone:770-683-8346
Mailing Address - Fax:770-502-2056
Practice Address - Street 1:2959 SHARPSBURG MCCULLUM RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2297
Practice Address - Country:US
Practice Address - Phone:770-683-8346
Practice Address - Fax:770-502-2056
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033061208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00427325AMedicaid
GA02BDBJFMedicare ID - Type Unspecified
GAC87658Medicare UPIN