Healthcare Provider Details

I. General information

NPI: 1316991870
Provider Name (Legal Business Name): JEROME D. HOMISH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7231 ROCKBRIDGE RD
LITHONIA GA
30058-5918
US

IV. Provider business mailing address

7231 ROCKBRIDGE RD
LITHONIA GA
30058-5918
US

V. Phone/Fax

Practice location:
  • Phone: 678-710-9270
  • Fax: 470-365-2880
Mailing address:
  • Phone: 678-710-9270
  • Fax: 478-365-2880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-005148
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number89940
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number89940
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: