Provider Demographics
NPI:1821031329
Name:THOMAS, DENNIS RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:RUSSELL
Last Name:THOMAS
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 1:4370 KINGS WAY
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-6904
Mailing Address - Country:US
Mailing Address - Phone:229-433-8181
Mailing Address - Fax:229-293-7801
Practice Address - Street 1:4370 KINGS WAY
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6904
Practice Address - Country:US
Practice Address - Phone:229-433-8181
Practice Address - Fax:229-293-7801
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022898207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA117939Medicaid
GA000260809EMedicaid
GA336042Medicaid
GA117939Medicaid