Basic Information
| Provider Information | |||||||||
| NPI: | 1033112438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESMOND | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | IV | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 SHORTER AVE NW | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301654290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093300 | ||||||||
| FaxNumber: | 7065093301 | ||||||||
| Practice Location | |||||||||
| Address1: | 304 SHORTER AVE NW | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301654290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093300 | ||||||||
| FaxNumber: | 7065093301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 52705 | GA | N | Other Service Providers | Specialist | 207Q00000X | 52705 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.