Provider Demographics
NPI:1366583270
Name:LOVE, DEXTER WAYNE (MD)
Entity type:Individual
Prefix:
First Name:DEXTER
Middle Name:WAYNE
Last Name:LOVE
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:PO BOX 3383
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-3383
Mailing Address - Country:US
Mailing Address - Phone:229-502-9730
Mailing Address - Fax:540-678-9025
Practice Address - Street 1:16 LIVE OAK CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768
Practice Address - Country:US
Practice Address - Phone:229-785-2400
Practice Address - Fax:229-502-9793
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0072717207X00000X
GA079989207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP01656331OtherRR MEDICARE
GA003205728AMedicaid
MDP01656331OtherRR MEDICARE