Provider Demographics
NPI:1700029402
Name:ALLEN, IDI (MD)
Entity Type:Individual
Prefix:DR
First Name:IDI
Middle Name:
Last Name:ALLEN
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 1:101 YORKTOWN DR STE 211
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1578
Mailing Address - Country:US
Mailing Address - Phone:470-481-2020
Mailing Address - Fax:770-703-4989
Practice Address - Street 1:101 YORKTOWN DR STE 211
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1578
Practice Address - Country:US
Practice Address - Phone:470-481-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA70849207L00000X, 207LP3000X, 208VP0000X, 208VP0014X, 207LP3000X
ALMD.32921207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine