Healthcare Provider Details

I. General information

NPI: 1639831548
Provider Name (Legal Business Name): CALLIE WILKES HAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 HARRIS INDUSTRIAL BLVD STE 3
VIDALIA GA
30474-8854
US

IV. Provider business mailing address

1706 KNOLLWOOD ST
VIDALIA GA
30474-5454
US

V. Phone/Fax

Practice location:
  • Phone: 912-537-9355
  • Fax:
Mailing address:
  • Phone: 912-326-4159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10722
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: