Provider Demographics
NPI:1730126194
Name:URSAL, CONCORDIO F (MD)
Entity Type:Individual
Prefix:
First Name:CONCORDIO
Middle Name:F
Last Name:URSAL
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 1:202 SOUTH CHERRY STREET
Mailing Address - Street 2:
Mailing Address - City:OCILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31774
Mailing Address - Country:US
Mailing Address - Phone:229-468-5015
Mailing Address - Fax:912-383-6365
Practice Address - Street 1:2106 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533
Practice Address - Country:US
Practice Address - Phone:912-384-4010
Practice Address - Fax:912-383-6365
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019352208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000474977LMedicaid
GA000474977QMedicaid
GA000474977MMedicaid
GA000474977TMedicaid
GA000474977LMedicaid
GAGRP2584Medicare PIN