Provider Demographics
NPI:1164684304
Name:COLE, JOHN ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:COLE
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 1:2410N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2533
Mailing Address - Country:US
Mailing Address - Phone:229-241-7546
Mailing Address - Fax:229-469-5722
Practice Address - Street 1:2410N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2533
Practice Address - Country:US
Practice Address - Phone:229-241-7546
Practice Address - Fax:229-469-5722
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065951207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I077955OtherMEDICARE PTAN