Healthcare Provider Details

I. General information

NPI: 1619909827
Provider Name (Legal Business Name): BRIAN D ALLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 MILSTEAD AVE NE
CONYERS GA
30012-3877
US

IV. Provider business mailing address

1412 MILSTEAD AVE ROCKDALE MEDICAL CENTER WOUND CARE
CONYERS GA
30012
US

V. Phone/Fax

Practice location:
  • Phone: 678-413-7738
  • Fax:
Mailing address:
  • Phone: 678-413-7738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number070848
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: