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General NPI Number Information
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NPI Number | 1104022425
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Entity Type | Organization
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Legal Business Name | C. WAYNE DODGEN, MD, PC
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Dates
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Enumeration Date | 06/24/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 107 JACKSON AVE SUITE A
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City | THOMASTON
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State | GA
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Zip | 30286-3433
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Country | US
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Telephone | 706-647-8101
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Fax | 706-647-8543
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Provider Business Mailing Address
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Address Line | PO BOX 4867
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City | MACON
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State | GA
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Zip | 31208-4867
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Country | US
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Telephone | 706-647-8101
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Fax | 706-647-8543
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Authorized Official
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Title or Position | CEO
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Name | DR. CHARLES WAYNE DODGEN
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Credential | M.D.
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Telephone | 706-647-8101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State | GA
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