Healthcare Provider Details

I. General information

NPI: 1346792538
Provider Name (Legal Business Name): CLARKESVILLE DERMATOLOGY & MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 09/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5330 HIGHWAY 115
CLARKESVILLE GA
30523-6730
US

IV. Provider business mailing address

5330 HIGHWAY 115
CLARKESVILLE GA
30523-6730
US

V. Phone/Fax

Practice location:
  • Phone: 706-754-5991
  • Fax: 706-754-6736
Mailing address:
  • Phone: 706-754-5991
  • Fax: 706-754-6736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER B GRAY
Title or Position: PHYSICIAN ASSISTANT
Credential: PA
Phone: 706-754-5991