Provider Demographics
NPI:1699706911
Name:DODSON, GREGORY E (PAC)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:E
Last Name:DODSON
Suffix:
Gender:M
Credentials:PAC
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 1479
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-1479
Mailing Address - Country:US
Mailing Address - Phone:229-227-5510
Mailing Address - Fax:229-227-5527
Practice Address - Street 1:454 SMITH AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5535
Practice Address - Country:US
Practice Address - Phone:229-227-5510
Practice Address - Fax:229-227-5527
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPA693363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291323200Medicaid
GA100000147BMedicaid
GA100000147BMedicaid
GA97WCHZXMedicare PIN
FLE65792Medicare ID - Type Unspecified