Provider Demographics
NPI:1104022425
Name:C. WAYNE DODGEN, MD, PC
Entity Type:Organization
Organization Name:C. WAYNE DODGEN, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:DODGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-647-8101
Mailing Address - Street 1:PO BOX 4867
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4867
Mailing Address - Country:US
Mailing Address - Phone:706-647-8101
Mailing Address - Fax:706-647-8543
Practice Address - Street 1:107 JACKSON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3433
Practice Address - Country:US
Practice Address - Phone:706-647-8101
Practice Address - Fax:706-647-8543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11DO948247OtherCLIA #