Healthcare Provider Details

I. General information

NPI: 1366481848
Provider Name (Legal Business Name): EARL S GOLIGHTLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 SOUTH 9TH STREET
GRIFFIN GA
30224
US

IV. Provider business mailing address

681 SOUTH 9TH STREET
GRIFFIN GA
30224
US

V. Phone/Fax

Practice location:
  • Phone: 770-228-5745
  • Fax: 770-228-5317
Mailing address:
  • Phone: 770-228-5745
  • Fax: 770-228-5317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number22148
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: