Provider Demographics
NPI:1689655904
Name:DORMINEY, HENRY CLAYTON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:CLAYTON
Last Name:DORMINEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 LOVE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-4071
Mailing Address - Country:US
Mailing Address - Phone:229-382-3720
Mailing Address - Fax:229-382-3722
Practice Address - Street 1:820 LOVE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4071
Practice Address - Country:US
Practice Address - Phone:229-382-3720
Practice Address - Fax:229-382-3722
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023352174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000239731AMedicaid
GAE54853Medicare UPIN