Provider Demographics
NPI:1780943043
Name:MADSEN, JACK ENOCH IV (DPM)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:ENOCH
Last Name:MADSEN
Suffix:IV
Gender:M
Credentials:DPM
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Mailing Address - Street 1:900 CIRCLE 75 PKWY SE
Mailing Address - Street 2:STE. 900
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3035
Mailing Address - Country:US
Mailing Address - Phone:678-426-2171
Mailing Address - Fax:404-446-1957
Practice Address - Street 1:5445 MERIDIAN MARK RD
Practice Address - Street 2:STE. 390
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4763
Practice Address - Country:US
Practice Address - Phone:404-237-3668
Practice Address - Fax:404-237-9563
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2022-02-10
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Provider Licenses
StateLicense IDTaxonomies
GAPOD001281213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist