Basic Information
| Provider Information | |||||||||
| NPI: | 1780943043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADSEN | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | ENOCH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 CIRCLE 75 PKWY SE | ||||||||
| Address2: | STE. 900 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303393035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784262171 | ||||||||
| FaxNumber: | 4044461957 | ||||||||
| Practice Location | |||||||||
| Address1: | 5445 MERIDIAN MARK RD | ||||||||
| Address2: | STE. 390 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303424763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042373668 | ||||||||
| FaxNumber: | 4042379563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2012 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | POD001281 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.