Facts
- Status
- A
- Credential
- MD
- Type
- Individual
- Enumeration date
- 2013-08-28
- Last updated
- 2024-11-08
Licenses
- License TN
- 61140
- License SC
- 86367
- License TN
- 61140
- License GA
- 89578
- License SC
- 86367
- License GA
- 89578
Location
- Practice location
- 807 S LAUREL ST STE B
- City
- SPRINGFIELD GA
- Postal code
- 313299273
- Phone
- 912-812-1005
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.