Healthcare Provider Details

I. General information

NPI: 1023837135
Provider Name (Legal Business Name): GEORGIA UROLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 BIG A RD
TOCCOA GA
30577-6017
US

IV. Provider business mailing address

1930 BRANNAN RD
MCDONOUGH GA
30253-4310
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-8765
  • Fax:
Mailing address:
  • Phone: 678-284-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARK A HABER
Title or Position: MD
Credential:
Phone: 678-284-4040