Healthcare Provider Details

I. General information

NPI: 1871703868
Provider Name (Legal Business Name): JUSTIN D LOVVORN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 E HIGHWAY 166
BOWDON GA
30108-2401
US

IV. Provider business mailing address

119 AMBULANCE DR SUITE 202
CARROLLTON GA
30117-3857
US

V. Phone/Fax

Practice location:
  • Phone: 770-258-5424
  • Fax:
Mailing address:
  • Phone: 770-836-9250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number062249
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: