Provider Demographics
NPI:1336345487
Name:POWELLSON, MATTHEW DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DANIEL
Last Name:POWELLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1449 BRAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0854
Mailing Address - Country:US
Mailing Address - Phone:912-871-2900
Mailing Address - Fax:912-871-3901
Practice Address - Street 1:1310 BRAMPTON AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0851
Practice Address - Country:US
Practice Address - Phone:912-486-1873
Practice Address - Fax:912-486-2394
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066402208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics