1790841120 NPI number — BARBARA A DAMPOG M.D

Table of content: BARBARA A DAMPOG M.D (NPI 1790841120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790841120 NPI number — BARBARA A DAMPOG M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAMPOG
Provider First Name:
BARBARA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
F

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:
1790841120
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6179 WINDSONG WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30087-1945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-923-5495
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 BUCKEYE RD
Provider Second Line Business Practice Location Address:
SUITE 178
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30341-4229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-458-6103
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/29/2006

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: 207ZC0500X , with the licence number:  018136 , 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)

  • Identifier: 000266175C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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