Provider Demographics
NPI:1871024802
Name:PODESTA, TIMOTHY ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:PODESTA
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 1:200 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2997
Mailing Address - Country:US
Mailing Address - Phone:478-751-0181
Mailing Address - Fax:
Practice Address - Street 1:200 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2981
Practice Address - Country:US
Practice Address - Phone:478-274-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA86347207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003242899AMedicaid
GA003242899BMedicaid
GA003242899CMedicaid