Healthcare Provider Details

I. General information

NPI: 1275860900
Provider Name (Legal Business Name): OCONEE PRIMARY CARE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 11/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 MARS HILL RD SUITE B
WATKINSVILLE GA
30677-4813
US

IV. Provider business mailing address

1624 MARS HILL RD SUITE B
WATKINSVILLE GA
30677-4813
US

V. Phone/Fax

Practice location:
  • Phone: 404-759-6436
  • Fax: 706-769-2750
Mailing address:
  • Phone: 404-759-6436
  • Fax: 706-769-2750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number050049
License Number StateGA

VIII. Authorized Official

Name: KEN H PARK
Title or Position: OWNER/PROVIDER
Credential: MD
Phone: 404-759-6436