Healthcare Provider Details

I. General information

NPI: 1780203547
Provider Name (Legal Business Name): DANIEL LAMAR ALLEN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 COLUMBIA RD STE 103
MARTINEZ GA
30907-1482
US

IV. Provider business mailing address

4106 COLUMBIA RD STE 103
MARTINEZ GA
30907-1482
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-1440
  • Fax: 706-863-5418
Mailing address:
  • Phone: 706-863-1440
  • Fax: 706-863-5418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number95930
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: