Provider Demographics
NPI:1194701649
Name:CHURCH, JOHN CLAYTON (MD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CLAYTON
Last Name:CHURCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1207
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30722-1207
Mailing Address - Country:US
Mailing Address - Phone:706-278-9729
Mailing Address - Fax:706-226-9378
Practice Address - Street 1:1502 N THORNTON AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3064
Practice Address - Country:US
Practice Address - Phone:706-278-9729
Practice Address - Fax:706-226-9378
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0235752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00248245FMedicaid
GA30BDCDXMedicare ID - Type Unspecified
GA00248245FMedicaid