Healthcare Provider Details

I. General information

NPI: 1184692790
Provider Name (Legal Business Name): WESLEY DON ENSLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 TOWNE CENTER BLVD BLDG 1200
POOLER GA
31322-4129
US

IV. Provider business mailing address

1000 TOWNE CENTER BLVD BLDG 1200
POOLER GA
31322-4129
US

V. Phone/Fax

Practice location:
  • Phone: 912-748-2280
  • Fax: 912-748-4988
Mailing address:
  • Phone: 912-748-2280
  • Fax: 912-748-4988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number046086
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: