Healthcare Provider Details

I. General information

NPI: 1871707489
Provider Name (Legal Business Name): COKER PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 03/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14557 HIGHWAY 19 SUITE A
GRIFFIN GA
30224-9582
US

IV. Provider business mailing address

14557 HIGHWAY 19 SUITE A
GRIFFIN GA
30224-9582
US

V. Phone/Fax

Practice location:
  • Phone: 678-688-1580
  • Fax: 678-688-1594
Mailing address:
  • Phone: 678-688-1580
  • Fax: 678-688-1594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number056276
License Number StateGA

VIII. Authorized Official

Name: MARK ALLEN COKER
Title or Position: MEMBER
Credential: M.D.
Phone: 678-688-1580