Healthcare Provider Details

I. General information

NPI: 1376625087
Provider Name (Legal Business Name): JOHN C EARLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 06/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 CROFT ST
CARROLLTON GA
30117-3863
US

IV. Provider business mailing address

251 CROFT ST
CARROLLTON GA
30117-3863
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-7117
  • Fax:
Mailing address:
  • Phone: 770-834-7117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number032723
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: