Provider Demographics
NPI:1629023486
Name:BAILON, BENJAMIN BARROGA (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BARROGA
Last Name:BAILON
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 1:40 HIGHWAY 122 CONNECTOR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:GA
Mailing Address - Zip Code:31635-5713
Mailing Address - Country:US
Mailing Address - Phone:229-563-0098
Mailing Address - Fax:
Practice Address - Street 1:116 ROSEDALE AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6655
Practice Address - Country:US
Practice Address - Phone:229-228-6577
Practice Address - Fax:229-228-4708
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027025207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00294137AMedicaid
GA00294137AMedicaid