1649419821 NPI number — MS. CARMEN MELTON DOUGLAS MED

Table of content: MS. CARMEN MELTON DOUGLAS MED (NPI 1649419821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649419821 NPI number — MS. CARMEN MELTON DOUGLAS MED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGLAS
Provider First Name:
CARMEN
Provider Middle Name:
MELTON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MED
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:
1649419821
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1415 HIGHWAY 85 N
Provider Second Line Business Mailing Address:
# 310-172
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-7738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-317-4140
Provider Business Mailing Address Fax Number:
770-603-9072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10354 SHEPPERTON COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-317-4140
Provider Business Practice Location Address Fax Number:
770-603-9072
Provider Enumeration Date:
02/12/2009

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: 235Z00000X , with the licence number:  SLP005253 , 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: 000946558D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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