Provider Demographics
NPI:1124023023
Name:PATRICK, JOHN W (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:PATRICK
Suffix:
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:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-0008
Mailing Address - Country:US
Mailing Address - Phone:706-647-8111
Mailing Address - Fax:706-647-4389
Practice Address - Street 1:801 W GORDON ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3426
Practice Address - Country:US
Practice Address - Phone:706-647-8111
Practice Address - Fax:706-647-4389
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0114382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA520322900001OtherBLUE CROSS
GA30BDLMLMedicare ID - Type Unspecified
GA30BDLXZMedicare ID - Type Unspecified
GA520322900001OtherBLUE CROSS