Healthcare Provider Details

I. General information

NPI: 1316931017
Provider Name (Legal Business Name): WILLIAM G IRWIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 HOSPITAL DR STE C
WARNER ROBINS GA
31088-4207
US

IV. Provider business mailing address

2400 BELLEVUE RD SUITE 21-A
DUBLIN GA
31021-2885
US

V. Phone/Fax

Practice location:
  • Phone: 478-922-9281
  • Fax: 478-328-0438
Mailing address:
  • Phone: 478-275-7202
  • Fax: 478-274-8418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number012172
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number012172
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number012172
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number012172
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number012172
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: