Provider Demographics
NPI:1932297868
Name:POTTINGER PICKENS, BEVERLY (DO)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:POTTINGER PICKENS
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 1:6095 PROFESSIONAL PKWY
Mailing Address - Street 2:SUITE A210
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5607
Mailing Address - Country:US
Mailing Address - Phone:770-949-4188
Mailing Address - Fax:770-949-1614
Practice Address - Street 1:6095 PROFESSIONAL PKWY
Practice Address - Street 2:SUITE A210
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5607
Practice Address - Country:US
Practice Address - Phone:770-949-4188
Practice Address - Fax:770-949-1614
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052002207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA811423149AMedicaid
GA811423149AMedicaid