Provider Demographics
NPI:1184884793
Name:WINDHAM, ADDIS DANIEL (MD)
Entity type:Individual
Prefix:
First Name:ADDIS
Middle Name:DANIEL
Last Name:WINDHAM
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 1:253 GARLAND BRISTOL ROAD
Mailing Address - Street 2:
Mailing Address - City:SAUTEE
Mailing Address - State:GA
Mailing Address - Zip Code:30571-2703
Mailing Address - Country:US
Mailing Address - Phone:706-878-2664
Mailing Address - Fax:706-878-2664
Practice Address - Street 1:253 GARLAND BRISTOL RD
Practice Address - Street 2:
Practice Address - City:SAUTEE
Practice Address - State:GA
Practice Address - Zip Code:30571-2703
Practice Address - Country:US
Practice Address - Phone:706-878-2664
Practice Address - Fax:706-878-2664
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0138102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300108014OtherRAILROAD MEDICARE
GA000073169DMedicaid
D31396Medicare UPIN
GA000073169DMedicaid