Individual
JOSEPHINE T EDIALE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
626 DALLAS HWY, VILLA RICA, GA 30180-1209
(770) 459-9378
(770) 459-8613
Mailing address
4480 BLUE RIDGE DRIVE, DOUGLASVILLE, GA 30135-1800
(770) 459-9378
(770) 459-8613
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
050514
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000922732
PEACHSTATE
GA
05
—
000922732C
—
GA
01
—
01065140
AMERIGROUP
GA
01
—
305728
WELLCARE
GA
Enumeration date
12/05/2005
Last updated
10/07/2014
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