Basic Information
| Provider Information | |||||||||
| NPI: | 1558341057 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGICAL CLINIC OF VALDOSTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7494 EULIE WOOD DR | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316011144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292479124 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 N PATTERSON ST | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316021711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292411188 | ||||||||
| FaxNumber: | 2292457106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EATON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | ERIC | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 2292429003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MPAS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 018627 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 1032904 | 01 | NCCPA | OTHER |