Provider Demographics
NPI:1922242759
Name:DUELLO, KATHERINE M (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:DUELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 DEEP SOUTH FARM RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-2220
Mailing Address - Country:US
Mailing Address - Phone:706-439-6380
Mailing Address - Fax:706-439-6398
Practice Address - Street 1:191 DEEP SOUTH FARM RD
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-2220
Practice Address - Country:US
Practice Address - Phone:706-439-6380
Practice Address - Fax:706-439-6398
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA076520207RC0000X
FLME107697207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006248600Medicaid
FLHB189ZMedicare PIN