Healthcare Provider Details

I. General information

NPI: 1760493167
Provider Name (Legal Business Name): WEST GEORGIA DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 WHITESVILLE ST
LAGRANGE GA
30240-5903
US

IV. Provider business mailing address

1605 WHITESVILLE ST
LAGRANGE GA
30240-5903
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-5119
  • Fax: 706-882-0270
Mailing address:
  • Phone: 706-882-5119
  • Fax: 706-882-0270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number30949
License Number StateGA

VIII. Authorized Official

Name: DR. GARIN DANIEL BARTH
Title or Position: OWNER
Credential: MD
Phone: 706-882-5119