Provider Demographics
NPI:1902880842
Name:EDIALE, JOSEPHINE T (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:T
Last Name:EDIALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4480 BLUE RIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1800
Mailing Address - Country:US
Mailing Address - Phone:770-459-9378
Mailing Address - Fax:770-459-8613
Practice Address - Street 1:626 DALLAS HWY
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1209
Practice Address - Country:US
Practice Address - Phone:770-459-9378
Practice Address - Fax:770-459-8613
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050514208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000922732CMedicaid
GA000922732OtherPEACHSTATE
GA01065140OtherAMERIGROUP
GA305728OtherWELLCARE