Healthcare Provider Details

I. General information

NPI: 1528067337
Provider Name (Legal Business Name): ANDREA M THAXTON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

881 USS JAMES MADISON RD
KINGS BAY GA
31547-2531
US

IV. Provider business mailing address

881 USS JAMES MADISON RD
KINGS BAY GA
31547-2531
US

V. Phone/Fax

Practice location:
  • Phone: 912-573-4220
  • Fax: 912-573-2597
Mailing address:
  • Phone: 912-573-8801
  • Fax: 912-573-2597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME88475
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: