Healthcare Provider Details

I. General information

NPI: 1720583974
Provider Name (Legal Business Name): DAVID LLOYD WALDBURG V MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 08/07/2023
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 DIXIE ST
CARROLLTON GA
30117-4417
US

IV. Provider business mailing address

905 DIXIE ST
CARROLLTON GA
30117-4417
US

V. Phone/Fax

Practice location:
  • Phone: 770-812-5003
  • Fax: 770-812-5832
Mailing address:
  • Phone: 770-812-5003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number96204
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: