Healthcare Provider Details

I. General information

NPI: 1114698933
Provider Name (Legal Business Name): CHAMBLEE CHILDREN'S CLINIC , P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3337 CHAMBLEE DUNWOODY RD
CHAMBLEE GA
30341-2816
US

IV. Provider business mailing address

3337 CHAMBLEE DUNWOODY RD
CHAMBLEE GA
30341-2816
US

V. Phone/Fax

Practice location:
  • Phone: 770-457-3303
  • Fax: 770-457-3316
Mailing address:
  • Phone: 770-457-3303
  • Fax: 770-457-3316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JIONG FAN
Title or Position: MD
Credential: MD
Phone: 770-457-3303