=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255210076
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAMON INGRAM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2025
-----------------------------------------------------
Last Update Date | 10/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5665 PEACHTREE DUNWOODY RD
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-1764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-843-7001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 280 MERCHANTS DR UNIT 448
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30132-0702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-939-9610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | 100286589
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------