Provider Demographics
NPI:1225019821
Name:DAMPOG, ALFONSO T (MD)
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:T
Last Name:DAMPOG
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:PO BOX 116276
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6276
Mailing Address - Country:US
Mailing Address - Phone:770-232-8611
Mailing Address - Fax:770-232-8618
Practice Address - Street 1:2131 FOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-7024
Practice Address - Country:US
Practice Address - Phone:770-979-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018008207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE01016Medicare UPIN