Provider Demographics
NPI:1952472375
Name:ANGLYN, DERRELL WINSOR JR (MD)
Entity Type:Individual
Prefix:
First Name:DERRELL
Middle Name:WINSOR
Last Name:ANGLYN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 SIMS ST
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-2320
Mailing Address - Country:US
Mailing Address - Phone:770-957-3922
Mailing Address - Fax:770-957-5477
Practice Address - Street 1:55 SIMS ST
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-2320
Practice Address - Country:US
Practice Address - Phone:770-957-3922
Practice Address - Fax:770-957-5477
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024198207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00281487DMedicaid
GA08BDPLXMedicare PIN
D28800Medicare UPIN