Healthcare Provider Details

I. General information

NPI: 1306836747
Provider Name (Legal Business Name): ENID COLON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 03/07/2023
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 WALESKA RD STE 1C
CANTON GA
30114-2493
US

IV. Provider business mailing address

11770 HAYNES BRIDGE RD STE 205
ALPHARETTA GA
30009-1968
US

V. Phone/Fax

Practice location:
  • Phone: 770-345-0055
  • Fax: 770-345-0020
Mailing address:
  • Phone: 770-345-0055
  • Fax: 770-345-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number043020
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: