Healthcare Provider Details

I. General information

NPI: 1679871099
Provider Name (Legal Business Name): WALTON PULMONARY & SLEEP MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 TARA COMMONS DR
LOGANVILLE GA
30052-8018
US

IV. Provider business mailing address

101 TARA COMMONS DR
LOGANVILLE GA
30052-8018
US

V. Phone/Fax

Practice location:
  • Phone: 678-928-9700
  • Fax: 770-466-1585
Mailing address:
  • Phone: 678-928-9700
  • Fax: 770-466-1585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number065686
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number065686
License Number StateGA

VIII. Authorized Official

Name: DR. MICHEL JEANNOT
Title or Position: OWNER
Credential: MD
Phone: 678-928-9700