Provider Demographics
NPI:1649207648
Name:JETTON, CHUCK ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:CHUCK
Middle Name:ANDREW
Last Name:JETTON
Suffix:
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 1:1000 JOHNSON FY RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1606
Mailing Address - Country:US
Mailing Address - Phone:404-851-8000
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72792207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009995925Medicaid
AL010033CI29987OtherSECTION 1011
AL009995905Medicaid
AL051528339OtherBLUE CROSS
AL051528337OtherBLUE CROSS
AL009995915Medicaid
MS01326791OtherMISSISSIPPI MEDICAID
AL051528338OtherBLUE CROSS