Healthcare Provider Details

I. General information

NPI: 1558364919
Provider Name (Legal Business Name): MICHAEL J MAGBALON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2282 E PINETREE BLVD
THOMASVILLE GA
31792-4807
US

IV. Provider business mailing address

2282 E PINETREE BLVD
THOMASVILLE GA
31792-4807
US

V. Phone/Fax

Practice location:
  • Phone: 229-226-6000
  • Fax: 229-226-5859
Mailing address:
  • Phone: 229-226-6000
  • Fax: 229-226-5859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number58984
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: