Healthcare Provider Details

I. General information

NPI: 1912534215
Provider Name (Legal Business Name): JEFFREY DOVER MIMBS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31201-2102
US

IV. Provider business mailing address

1430 TULANE AVE # 8050
NEW ORLEANS LA
70112-2632
US

V. Phone/Fax

Practice location:
  • Phone: 478-331-1000
  • Fax:
Mailing address:
  • Phone: 504-988-7809
  • Fax: 504-988-3971

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 StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number99555
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: