Provider Demographics
NPI:1114241064
Name:FLETCHER, ERNEST L (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:L
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 EAGLES LANDING PKWY
Mailing Address - Street 2:STE 584
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7343
Mailing Address - Country:US
Mailing Address - Phone:678-314-8935
Mailing Address - Fax:
Practice Address - Street 1:80 VININGS DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5994
Practice Address - Country:US
Practice Address - Phone:678-284-6291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-22
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23994207Q00000X
GA64538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003202440AMedicaid