Healthcare Provider Details

I. General information

NPI: 1114021409
Provider Name (Legal Business Name): OBSTETRICS & GYNECOLOGY OF DOTHAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MEDICAL DR
DOTHAN AL
36303
US

IV. Provider business mailing address

104 MEDICAL DR
DOTHAN AL
36303
US

V. Phone/Fax

Practice location:
  • Phone: 334-671-9445
  • Fax: 334-836-0059
Mailing address:
  • Phone: 334-671-9445
  • Fax: 334-836-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number23245
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDO1161
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number31759
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number31756
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number32437
License Number StateAL
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-204
License Number StateAL
# 7
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number1006758
License Number StateAL
# 8
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateAL
# 9
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number26014
License Number StateAL

VIII. Authorized Official

Name: DANA GAYLORD
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 334-671-9445