Provider Demographics
NPI:1366076945
Name:WAJSWOL, ETHAN JACOB (MD (5/18/2020))
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:JACOB
Last Name:WAJSWOL
Suffix:
Gender:M
Credentials:MD (5/18/2020)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:
Practice Address - Street 1:470 NORTHSIDE CHEROKEE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8029
Practice Address - Country:US
Practice Address - Phone:770-720-7246
Practice Address - Fax:770-720-4620
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA99892208800000X
FLME153288208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology