Healthcare Provider Details

I. General information

NPI: 1396430856
Provider Name (Legal Business Name): MICAH GABRIEL ERNST MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 NORTHLAKE PKWY STE 201
TUCKER GA
30084-7070
US

IV. Provider business mailing address

4905 COURTNEY DR
FOREST PARK GA
30297-1427
US

V. Phone/Fax

Practice location:
  • Phone: 404-366-3636
  • Fax: 404-362-0808
Mailing address:
  • Phone: 404-366-3636
  • Fax: 404-362-0808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number114733
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: