Provider Demographics
NPI:1871583609
Name:ELLEBY, DOUGLAS H (DPM)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:H
Last Name:ELLEBY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 CIRCLE 75 PKWY.
Mailing Address - Street 2:STE. 900
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3084
Mailing Address - Country:US
Mailing Address - Phone:770-384-0284
Mailing Address - Fax:404-446-1957
Practice Address - Street 1:3825 MEDICAL PARK DR.
Practice Address - Street 2:STE. 200
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6831
Practice Address - Country:US
Practice Address - Phone:770-745-5101
Practice Address - Fax:770-745-9740
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000433213ES0103X
GAPOD000433213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000138993AMedicaid
LA1756385Medicaid
GA000138993AMedicaid