Provider Demographics
NPI:1134133523
Name:PHILLIPS, JERRY DAVID JR (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DAVID
Last Name:PHILLIPS
Suffix:JR
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 1:1518 MILULI AVE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4866
Mailing Address - Country:US
Mailing Address - Phone:229-248-8500
Mailing Address - Fax:229-248-8600
Practice Address - Street 1:1518 MILULI AVE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4866
Practice Address - Country:US
Practice Address - Phone:229-248-8500
Practice Address - Fax:229-248-8600
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042107207Q00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00749845FMedicaid
GA08BBQVZOtherMEDICARE-ID
GA08BBQVZOtherMEDICARE-ID