Provider Demographics
NPI:1871592774
Name:HENDRICKS, EDWIN PATTON JR (DO)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:PATTON
Last Name:HENDRICKS
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-0669
Mailing Address - Country:US
Mailing Address - Phone:706-778-3259
Mailing Address - Fax:706-776-8660
Practice Address - Street 1:720 MAINE ST
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-5222
Practice Address - Country:US
Practice Address - Phone:706-778-3259
Practice Address - Fax:706-776-8660
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2015-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA336067Medicaid
GA000235661BMedicaid
GA042720OtherBCBS OF GEORGIA
GA135382BFOtherPREFERRED HEALTH PLAN
GA581482841OtherTAX ID
GA010003405Medicare ID - Type UnspecifiedPALMETTO GBA RR MEDICARE
GA000235661BMedicaid
GA581482841OtherTAX ID