Provider Demographics
NPI:1245291616
Name:ALSOBROOK, JOHN ADDISON (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ADDISON
Last Name:ALSOBROOK
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:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:4889 GOLDEN PKWY STE 100
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-5878
Practice Address - Country:US
Practice Address - Phone:770-848-6190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 92466207Q00000X
GA059115207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA059115OtherSTATE LICENSE
GA552625560FMedicaid
GA552625560OMedicaid
GA552625560HMedicaid
GA511I08099Medicare PIN
GA552625560FMedicaid