Provider Demographics
NPI:1861462053
Name:FORDHAM, TONYA FOWLER (DO)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:FOWLER
Last Name:FORDHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 LUCKIE ST
Mailing Address - Street 2:STE F
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-0358
Mailing Address - Country:US
Mailing Address - Phone:912-366-1362
Mailing Address - Fax:912-366-1365
Practice Address - Street 1:18 LUCKIE ST
Practice Address - Street 2:STE F
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0358
Practice Address - Country:US
Practice Address - Phone:912-366-1362
Practice Address - Fax:912-366-1365
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049292207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
100442OtherBCBS
GA00947273AMedicaid
GA00947273AMedicaid
H59128Medicare UPIN
080184908Medicare ID - Type UnspecifiedRAILROAD-TRAVELERS MEDICA