Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 23774 | GA |
NPI | 1003076043 |
---|---|
Provider Name | Dr. Gerald Terrence O'donoghue |
First Address | Kingsland, GA 31548-7102 |
Second Address | Kingsland, GA 31548-7102 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2008 |
Last Update Date | 12/06/2008 |