Provider Demographics
NPI:1922752427
Name:WIREGRASS DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:WIREGRASS DERMATOLOGY, LLC
Other - Org Name:WIREGRASS DERMATOLOGY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:GARCIA
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-524-2808
Mailing Address - Street 1:804 N WILEY AVE
Mailing Address - Street 2:
Mailing Address - City:DONALSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:39845-1120
Mailing Address - Country:US
Mailing Address - Phone:229-524-2808
Mailing Address - Fax:229-524-1068
Practice Address - Street 1:804 N WILEY AVE
Practice Address - Street 2:
Practice Address - City:DONALSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:39845-1120
Practice Address - Country:US
Practice Address - Phone:229-524-2808
Practice Address - Fax:229-524-2738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-04
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1346433521OtherMD NPI
1255798047OtherPA NPI