Provider Demographics
NPI:1861659294
Name:COFFEE COUNTY PEDIATRICS PC
Entity Type:Organization
Organization Name:COFFEE COUNTY PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DYAPA
Authorized Official - Middle Name:S
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-384-2474
Mailing Address - Street 1:303B SHIRLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2333
Mailing Address - Country:US
Mailing Address - Phone:912-384-2474
Mailing Address - Fax:912-384-4995
Practice Address - Street 1:303B SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2333
Practice Address - Country:US
Practice Address - Phone:912-384-2474
Practice Address - Fax:912-384-4995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028307261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care