Healthcare Provider Details

I. General information

NPI: 1811799760
Provider Name (Legal Business Name): DOMINIQUE DEREK MUNROE MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST # 143
MACON GA
31201-2102
US

IV. Provider business mailing address

777 HEMLOCK STREET LN # 42
MACON GA
31201-2168
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-5500
  • Fax:
Mailing address:
  • Phone: 478-633-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18160
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: