Provider Demographics
NPI:1023232527
Name:NORTHUP, JOHN DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:NORTHUP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:12345 MERCY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-3436
Mailing Address - Country:US
Mailing Address - Phone:912-927-3046
Mailing Address - Fax:912-925-0597
Practice Address - Street 1:12345 MERCY BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-3436
Practice Address - Country:US
Practice Address - Phone:912-927-3046
Practice Address - Fax:912-925-0597
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016651207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000018092AMedicaid
GA110164346OtherRAILROAD MEDICARE
GA581263266OtherUNITED HEALTHCARE
GA581263266OtherUNITED HEALTHCARE