Provider Demographics
NPI:1538122478
Name:WASHINGTON, SIDNEY R III (MD)
Entity type:Individual
Prefix:
First Name:SIDNEY
Middle Name:R
Last Name:WASHINGTON
Suffix:III
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 1:1878 BRANNEN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-7257
Mailing Address - Country:US
Mailing Address - Phone:912-690-2724
Mailing Address - Fax:912-852-2041
Practice Address - Street 1:1878 BRANNEN LAKE RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-7257
Practice Address - Country:US
Practice Address - Phone:912-690-2724
Practice Address - Fax:912-852-2041
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028667174400000X
GA28667208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000326136AMedicaid
GA000326136AMedicaid