Provider Demographics
NPI:1932253101
Name:GATEWOOD, GEORGE (CPO,CPED)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:GATEWOOD
Suffix:
Gender:M
Credentials:CPO,CPED
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 1623
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-1623
Mailing Address - Country:US
Mailing Address - Phone:706-596-8004
Mailing Address - Fax:706-327-3388
Practice Address - Street 1:2403 MANCHESTER EXPY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6813
Practice Address - Country:US
Practice Address - Phone:706-596-8004
Practice Address - Fax:706-327-3388
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2253332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00919553AMedicaid
GAN343442OtherWELLCARE
GA138773OtherPEACHSTATE
GA00919553AMedicaid