Healthcare Provider Details

I. General information

NPI: 1396015343
Provider Name (Legal Business Name): DENNIS R THOMAS MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 01/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3374 GREYSTONE WAY
VALDOSTA GA
31605-1096
US

IV. Provider business mailing address

3374 GREYSTONE WAY
VALDOSTA GA
31605-1096
US

V. Phone/Fax

Practice location:
  • Phone: 229-247-9911
  • Fax: 229-247-8844
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22898
License Number StateGA

VIII. Authorized Official

Name: DENNIS RUSSELL THOMAS
Title or Position: PRESIDENT
Credential: PHYSICIAN
Phone: 229-247-9911