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General NPI Number Information
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NPI Number | 1154081271
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Entity Type | Organization
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Legal Business Name | TIFTAREA PEDIATRICS
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Dates
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Enumeration Date | 12/30/2021
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Last Update Date | 11/02/2022
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Provider Practice Location Address
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Address Line | 215 12TH ST W
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City | TIFTON
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State | GA
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Zip | 31794-3923
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Country | US
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Telephone | 912-690-4043
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Fax |
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Provider Business Mailing Address
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Address Line | 215 12TH ST W
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City | TIFTON
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State | GA
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Zip | 31794-3923
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Country | US
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Telephone | 912-690-4043
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | MARK WILSON
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Credential | MD
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Telephone | 229-396-5335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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