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General NPI Number Information
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NPI Number | 1649281791
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Entity Type | Organization
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Legal Business Name | MIDDLE GEORGIA UROLOGY, INC
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Dates
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Enumeration Date | 08/11/2006
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Last Update Date | 04/13/2009
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Provider Practice Location Address
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Address Line | 109 OSIGIAN BLVD SUITE 300
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City | WARNER ROBINS
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State | GA
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Zip | 31088-8922
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Country | US
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Telephone | 478-953-5074
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Fax | 478-953-0546
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Provider Business Mailing Address
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Address Line | 109 OSIGIAN BLVD
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City | WARNER ROBINS
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State | GA
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Zip | 31088-8922
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Country | US
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Telephone | 478-953-5074
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Fax | 478-953-0546
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Authorized Official
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Title or Position | OWNER
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Name | DANIEL A DEIGHTON
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Credential | MD
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Telephone | 478-953-5074
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 040361
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License Number State | GA
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