Basic Information
| Provider Information | |||||||||
| NPI: | 1154408938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESIMONE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 18TH ST E | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293533422 | ||||||||
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| Practice Location | |||||||||
| Address1: | 611 E WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ASHBURN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317145315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2295673407 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 11/11/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 019930 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000203365C | 05 | GA | MEDICAID | 019930 | 01 | GA | LICENSE NUMBER | OTHER |