Provider Demographics
NPI:1811981368
Name:BROYLES, JOHN A (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:BROYLES
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 1:2400 BELLEVUE RD
Mailing Address - Street 2:SUITE 21-A
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2885
Mailing Address - Country:US
Mailing Address - Phone:478-275-7202
Mailing Address - Fax:478-274-8418
Practice Address - Street 1:1157 FORSYTH ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7452
Practice Address - Country:US
Practice Address - Phone:478-745-8581
Practice Address - Fax:478-328-0438
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013257207NP0225X, 207NS0135X, 207N00000X, 208D00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00176976OtherRAILROAD MEDICARE
GADC4061OtherRAILROAD MEDICARE
GA000009501Medicaid
GADC4061OtherRAILROAD MEDICARE
GA000009501Medicaid
GAGRP6800Medicare PIN