Provider Demographics
NPI:1649281791
Name:MIDDLE GEORGIA UROLOGY, INC
Entity type:Organization
Organization Name:MIDDLE GEORGIA UROLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEIGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-953-5074
Mailing Address - Street 1:109 OSIGIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8922
Mailing Address - Country:US
Mailing Address - Phone:478-953-5074
Mailing Address - Fax:478-953-0546
Practice Address - Street 1:109 OSIGIAN BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8922
Practice Address - Country:US
Practice Address - Phone:478-953-5074
Practice Address - Fax:478-953-0546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040361208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty