Provider Demographics
NPI:1760530133
Name:INGRAHAM, RODDY PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:RODDY
Middle Name:PAUL
Last Name:INGRAHAM
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 1:2971 HURRICANE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY FACE
Mailing Address - State:GA
Mailing Address - Zip Code:30740-8716
Mailing Address - Country:US
Mailing Address - Phone:706-673-7889
Mailing Address - Fax:706-673-3628
Practice Address - Street 1:2971 HURRICANE RD
Practice Address - Street 2:
Practice Address - City:ROCKY FACE
Practice Address - State:GA
Practice Address - Zip Code:30740-8716
Practice Address - Country:US
Practice Address - Phone:706-673-7889
Practice Address - Fax:706-673-3628
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA139792080A0000X, 2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Not Answered2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00006982COtherPHYSICIAN IDENTIFICATION