Provider Demographics
NPI:1730171828
Name:VERNON, MINOR C (MD)
Entity type:Individual
Prefix:DR
First Name:MINOR
Middle Name:C
Last Name:VERNON
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 1:3951 RIDGE AVE
Mailing Address - Street 2:STE A
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-5050
Mailing Address - Country:US
Mailing Address - Phone:478-475-1006
Mailing Address - Fax:478-475-0787
Practice Address - Street 1:3951 RIDGE AVE
Practice Address - Street 2:STE A
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5050
Practice Address - Country:US
Practice Address - Phone:478-475-1006
Practice Address - Fax:478-475-0787
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020359208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4417613OtherAETNA PPO NUMBER
GA572632OtherBLUE CROSS BLUE SHIELD NO
GA1200048OtherUNITED HEALTHCARE NUMBER
GA00249213CMedicaid
GA37BBGXLMedicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE
GAD41288Medicare UPIN