Healthcare Provider Details

I. General information

NPI: 1922752427
Provider Name (Legal Business Name): WIREGRASS DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 N WILEY AVE
DONALSONVILLE GA
39845-1120
US

IV. Provider business mailing address

804 N WILEY AVE
DONALSONVILLE GA
39845-1120
US

V. Phone/Fax

Practice location:
  • Phone: 229-524-2808
  • Fax: 229-524-2738
Mailing address:
  • Phone: 229-524-2808
  • Fax: 229-524-1068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDREA GARCIA ALEXANDER
Title or Position: OFFICER/OWNER
Credential: MD
Phone: 229-524-2808