Healthcare Provider Details

I. General information

NPI: 1497851133
Provider Name (Legal Business Name): EDWIN ALONZO FARNELL IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 TOWN PARK LN
EVANS GA
30809-3481
US

IV. Provider business mailing address

1205 TOWN PARK LN
EVANS GA
30809-3481
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-3100
  • Fax: 706-228-3125
Mailing address:
  • Phone: 706-868-3100
  • Fax: 706-228-3125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number62689
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: