Provider Demographics
NPI:1770547101
Name:HACKNEY, WENDELL OLIVER (MD)
Entity type:Individual
Prefix:MR
First Name:WENDELL
Middle Name:OLIVER
Last Name:HACKNEY
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 1:7193 JONESBORO RD
Mailing Address - Street 2:FL 1
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2961
Mailing Address - Country:US
Mailing Address - Phone:770-961-2508
Mailing Address - Fax:770-961-2378
Practice Address - Street 1:7193 JONESBORO RD
Practice Address - Street 2:FL 1
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2961
Practice Address - Country:US
Practice Address - Phone:404-522-4888
Practice Address - Fax:404-581-0379
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024684207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
476807OtherAETNA
GA000258871Medicaid
238229OtherBCBS
D29649Medicare UPIN
GA000258871Medicaid