Basic Information
| Provider Information | |||||||||
| NPI: | 1386688554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COBB | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 89 INTERCHANGE DR | ||||||||
| Address2: | |||||||||
| City: | RICHMOND HILL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313247661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127562292 | ||||||||
| FaxNumber: | 9127562289 | ||||||||
| Practice Location | |||||||||
| Address1: | 89 INTERCHANGE DR | ||||||||
| Address2: | |||||||||
| City: | RICHMOND HILL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313247661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127564740 | ||||||||
| FaxNumber: | 9127564740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 039759 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10063650 | 01 | GA | AMERIGROUP | OTHER | 000696638B | 05 | GA | MEDICAID | 349738 | 01 | GA | WELLCARE | OTHER | 821615 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | 582162071019 | 01 | CHAMPUS | OTHER | 000696638F | 05 | GA | MEDICAID | 110214354 | 01 | RAILROAD MEDICARE | OTHER |