Provider Demographics
NPI:1740693696
Name:MASSENGILL, TRAVIS
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:MASSENGILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 WARM SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-7955
Mailing Address - Country:US
Mailing Address - Phone:706-243-4500
Mailing Address - Fax:706-243-4503
Practice Address - Street 1:2121 WARM SPRINGS RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-7955
Practice Address - Country:US
Practice Address - Phone:706-243-4500
Practice Address - Fax:706-243-4503
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151010877207R00000X
MIL283875207R00000X
GA83708207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine