Healthcare Provider Details

I. General information

NPI: 1154318004
Provider Name (Legal Business Name): ELEANOR WALAITIS CAMPBELL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: ELLIE J WALAITIS DO

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 JOHNS CREEK CT SUITE A
SUWANEE GA
30024-1265
US

IV. Provider business mailing address

3925 JOHNS CREEK CT SUITE A
SUWANEE GA
30024-1265
US

V. Phone/Fax

Practice location:
  • Phone: 678-474-4742
  • Fax: 678-474-0095
Mailing address:
  • Phone: 678-474-4742
  • Fax: 678-474-0095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number033741
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: