1891106795 NPI number — HENRY LEBOYD III MD

Table of content: HENRY LEBOYD III MD (NPI 1891106795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891106795 NPI number — HENRY LEBOYD III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEBOYD
Provider First Name:
HENRY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891106795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
907 18TH ST E STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31794-3690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-353-3450
Provider Business Mailing Address Fax Number:
229-353-6060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 18TH ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIFTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31794-3648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-382-7120
Provider Business Practice Location Address Fax Number:
229-353-6060
Provider Enumeration Date:
05/13/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 078692 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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