Provider Demographics
NPI:1437298957
Name:DERMATOLOGY SPECIALISTS OF GEORGIA, LLC
Entity Type:Organization
Organization Name:DERMATOLOGY SPECIALISTS OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:R
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-233-3376
Mailing Address - Street 1:2505 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4464
Mailing Address - Country:US
Mailing Address - Phone:877-231-3376
Mailing Address - Fax:850-522-8354
Practice Address - Street 1:658 N CHASE STREET UNIT 102
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601
Practice Address - Country:US
Practice Address - Phone:877-231-3376
Practice Address - Fax:850-522-8354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA18041207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA30926OtherWELLCARE
GA10059273OtherAMERIGROUP
GA000084961BMedicaid
GA000084961BMedicaid