Provider Demographics
NPI:1033112438
Name:DESMOND, JOHN J IV (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:DESMOND
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E 2ND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3210
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:
Practice Address - Street 1:304 SHORTER AVE NW
Practice Address - Street 2:SUITE 201
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-4290
Practice Address - Country:US
Practice Address - Phone:706-509-3300
Practice Address - Fax:706-509-3301
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA52705174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA152035826AMedicaid
GA202I082082Medicare PIN
H83193Medicare UPIN
GA152035826AMedicaid