Healthcare Provider Details

I. General information

NPI: 1992870190
Provider Name (Legal Business Name): EDWIN P HENDRICKS, JR. DO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 DEMOREST MOUNT AIRY HWY
DEMOREST GA
30535-5003
US

IV. Provider business mailing address

PO BOX 669
DEMOREST GA
30535-0669
US

V. Phone/Fax

Practice location:
  • Phone: 706-778-3259
  • Fax: 706-776-8660
Mailing address:
  • Phone: 706-778-3259
  • Fax: 706-776-8660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number022153
License Number StateGA

VIII. Authorized Official

Name: DR. EDWIN HENDRICKS, JR
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 706-778-3259