Healthcare Provider Details

I. General information

NPI: 1386753754
Provider Name (Legal Business Name): TIMOTHY LONGAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST HB 64
MACON GA
31201-2102
US

IV. Provider business mailing address

175 RIVOLI DOWNS DR
MACON GA
31210-8611
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-2097
  • Fax: 478-633-7836
Mailing address:
  • Phone: 478-477-5480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number025883
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: