Provider Demographics
NPI:1780680462
Name:AVIDANO, MICHAEL ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:AVIDANO
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1101 HOSPITAL DR
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9075
Mailing Address - Country:US
Mailing Address - Phone:770-474-7416
Mailing Address - Fax:770-389-6210
Practice Address - Street 1:1101 HOSPITAL DR
Practice Address - Street 2:STE 100A
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9076
Practice Address - Country:US
Practice Address - Phone:770-474-7416
Practice Address - Fax:770-389-6210
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2010-01-04
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Provider Licenses
StateLicense IDTaxonomies
GA039722207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000674726Medicaid
GA000674726Medicaid