Provider Demographics
NPI:1053531764
Name:MORGAN, GWENDOLYN VICKERY (MD)
Entity type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:VICKERY
Last Name:MORGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GWEN
Other - Middle Name:V
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:181 N VALHALLA DR
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-9304
Mailing Address - Country:US
Mailing Address - Phone:229-273-0369
Mailing Address - Fax:
Practice Address - Street 1:415 N JACKSON ST
Practice Address - Street 2:PO DRAWER 1348
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3015
Practice Address - Country:US
Practice Address - Phone:229-931-2470
Practice Address - Fax:229-931-2474
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0240402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26BDFNGMedicare ID - Type Unspecified
GAD42110Medicare UPIN