Provider Demographics
NPI:1386694990
Name:TACKITT, BOBBY O II (MD)
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:O
Last Name:TACKITT
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:699 CHURCH ST NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1110
Mailing Address - Country:US
Mailing Address - Phone:770-422-8700
Mailing Address - Fax:770-425-7601
Practice Address - Street 1:699 CHURCH ST NE
Practice Address - Street 2:SUITE 300
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1110
Practice Address - Country:US
Practice Address - Phone:770-422-8700
Practice Address - Fax:770-425-7601
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2014-01-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA47267207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00824249AMedicaid
GAG18295Medicare UPIN
GA16BDSXNMedicare ID - Type Unspecified
GA160052161Medicare PIN