Provider Demographics
NPI:1629028386
Name:DEAN, GWENDOLYN T (MD)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:T
Last Name:DEAN
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:PO BOX 56158
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30343-0158
Mailing Address - Country:US
Mailing Address - Phone:404-307-9575
Mailing Address - Fax:
Practice Address - Street 1:115 SUMNER RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4758
Practice Address - Country:US
Practice Address - Phone:678-477-6904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA28526174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00297349ALMedicaid
GA37BBGZKMedicare ID - Type Unspecified
GAD32807Medicare UPIN