Provider Demographics
NPI:1841296019
Name:AYDELOTT, GEORGE A (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:A
Last Name:AYDELOTT
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 1:3560 DELAWARE ST STE 209
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-3059
Mailing Address - Country:US
Mailing Address - Phone:409-899-3682
Mailing Address - Fax:409-898-0834
Practice Address - Street 1:3560 DELAWARE ST STE 209
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-3059
Practice Address - Country:US
Practice Address - Phone:409-899-3682
Practice Address - Fax:409-898-0834
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ04322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00152144OtherRAILROAD-MEDICARE
TX045187404Medicaid
TXP00152144OtherRAILROAD-MEDICARE