Provider Demographics
NPI:1144234733
Name:CAMILO, JOEL (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:CAMILO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOEL
Other - Middle Name:
Other - Last Name:CAMILO LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1355 PEACHTREE ST NE STE 1600
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3276
Mailing Address - Country:US
Mailing Address - Phone:678-223-7774
Mailing Address - Fax:678-223-7799
Practice Address - Street 1:1505 NORTHSIDE BLVD
Practice Address - Street 2:SUITE 2000
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041
Practice Address - Country:US
Practice Address - Phone:770-781-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA073459207RG0100X
MO2007035057207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003158042AMedicaid
MO1144234733Medicaid