Basic Information
| Provider Information | |||||||||
| NPI: | 1760023634 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN UROLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 W MAIN ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363051306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347939564 | ||||||||
| FaxNumber: | 3346718907 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 W MAIN ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363051306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347939564 | ||||||||
| FaxNumber: | 3346718907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2019 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | DEIGHTON | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3347939564 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.