Healthcare Provider Details

I. General information

NPI: 1811999402
Provider Name (Legal Business Name): ELIZABETH G WHITAKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 COBB GALLERIA PKWY STE 205
ATLANTA GA
30339-5919
US

IV. Provider business mailing address

3200 COBB GALLERIA PKWY STE 205
ATLANTA GA
30339-5919
US

V. Phone/Fax

Practice location:
  • Phone: 770-850-0202
  • Fax: 770-850-0022
Mailing address:
  • Phone: 770-850-0202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number041239
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number041239
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: