Healthcare Provider Details

I. General information

NPI: 1912108796
Provider Name (Legal Business Name): WARREN ROGER THOMAS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 RUSSELL HILL ESTATES DRIVE. NW
SUGAR VALLEY GA
30746
US

IV. Provider business mailing address

135 RUSSELL HILL ESTATES DRIVE. NW
SUGAR VALLEY GA
30746
US

V. Phone/Fax

Practice location:
  • Phone: 706-624-0552
  • Fax: 706-624-0552
Mailing address:
  • Phone: 706-624-0552
  • Fax: 706-624-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number046567
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: