Healthcare Provider Details

I. General information

NPI: 1942462627
Provider Name (Legal Business Name): JOHN DREW PROSSER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1499 WALTON WAY STE. 1400
AUGUSTA GA
30901-2602
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-3052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number073632
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: