Healthcare Provider Details

I. General information

NPI: 1275441073
Provider Name (Legal Business Name): MOBILE SONOGRAPHY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 LAKE SHORE BLVD
PORT WENTWORTH GA
31407-3612
US

IV. Provider business mailing address

21 LAKE SHORE BLVD
PORT WENTWORTH GA
31407-3612
US

V. Phone/Fax

Practice location:
  • Phone: 912-704-1053
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGEL THOMAS
Title or Position: SONOGRAPHER
Credential: RVT,RDMS
Phone: 912-704-1053