Provider Demographics
NPI:1366513210
Name:FAUSETT, THOMAS D JR (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:FAUSETT
Suffix:JR
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 1:707 N PARRISH AVE
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620
Mailing Address - Country:US
Mailing Address - Phone:229-896-7007
Mailing Address - Fax:229-896-7627
Practice Address - Street 1:707 N PARRISH AVE
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620
Practice Address - Country:US
Practice Address - Phone:229-896-7007
Practice Address - Fax:229-896-7627
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00801754FMedicaid
GA08BBVSSMedicare ID - Type Unspecified
GA00801754FMedicaid