Provider Demographics
NPI:1063460236
Name:DOROUGH, JOHN MICHAEL (AA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:DOROUGH
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 RAYMONDS GRANT TRCE
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-5393
Mailing Address - Country:US
Mailing Address - Phone:912-571-0808
Mailing Address - Fax:
Practice Address - Street 1:161 RAYMONDS GRANT TRCE
Practice Address - Street 2:
Practice Address - City:SAINT SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-5393
Practice Address - Country:US
Practice Address - Phone:912-638-9734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001777363A00000X
FLAA91367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001809AMedicaid
GA100001811BMedicaid
GAP00410144OtherRRB
GA32BBCGJMedicare UPIN
GA97BBGMJMedicare ID - Type Unspecified
GAP00410144Medicare PIN
GA32BBCGJMedicare PIN
GA100001811BMedicaid
GA43BBCGJMedicare PIN