Provider Demographics
NPI:1831107234
Name:PATTERSON, MARIAN ANTOINETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIAN
Middle Name:ANTOINETTE
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANTOINETTE
Other - Middle Name:PATTERSON
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2876
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2876
Mailing Address - Country:US
Mailing Address - Phone:229-891-9131
Mailing Address - Fax:
Practice Address - Street 1:3131 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6925
Practice Address - Country:US
Practice Address - Phone:229-502-9782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042035207QA0000X, 207QA0505X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000738944IMedicaid
GA260042741OtherTRI-CARE
GA260042741OtherTRI-CARE
GA08CBCSKMedicare PIN