Provider Demographics
NPI:1922043009
Name:TWEDT, GORDON H (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:H
Last Name:TWEDT
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 1:2309 MASTERS CT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-2073
Mailing Address - Country:US
Mailing Address - Phone:229-894-4688
Mailing Address - Fax:229-883-1579
Practice Address - Street 1:2309 MASTERS CT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-2073
Practice Address - Country:US
Practice Address - Phone:229-894-4688
Practice Address - Fax:229-883-1579
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0328302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004220045AMedicaid
GA004220045AMedicaid
GAD95396Medicare UPIN