Healthcare Provider Details

I. General information

NPI: 1467825281
Provider Name (Legal Business Name): J DEWAYNE COLQUITT MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 COLLIER RD NW STE 675
ATLANTA GA
30309-1612
US

IV. Provider business mailing address

1173 CITADEL DR NE
ATLANTA GA
30324-3815
US

V. Phone/Fax

Practice location:
  • Phone: 404-355-9255
  • Fax: 404-355-5822
Mailing address:
  • Phone: 404-355-9255
  • Fax: 404-355-5822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES DEWAYNE COLQUITT
Title or Position: OWNER
Credential: M.D.
Phone: 404-735-0208