Provider Demographics
NPI:1558341057
Name:UROLOGICAL CLINIC OF VALDOSTA
Entity Type:Organization
Organization Name:UROLOGICAL CLINIC OF VALDOSTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:MPAS
Authorized Official - Phone:229-242-9003
Mailing Address - Street 1:7494 EULIE WOOD DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-1144
Mailing Address - Country:US
Mailing Address - Phone:229-247-9124
Mailing Address - Fax:
Practice Address - Street 1:3000 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1711
Practice Address - Country:US
Practice Address - Phone:229-241-1188
Practice Address - Fax:229-245-7106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018627261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1032904OtherNCCPA