Provider Demographics
NPI:1255302675
Name:HOWARD, SELWYNN BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:SELWYNN
Middle Name:BRIAN
Last Name:HOWARD
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 1078
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-1078
Mailing Address - Country:US
Mailing Address - Phone:770-388-7745
Mailing Address - Fax:770-922-0526
Practice Address - Street 1:1359 MILSTEAD RD NE
Practice Address - Street 2:SUITE 103
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3865
Practice Address - Country:US
Practice Address - Phone:770-388-7745
Practice Address - Fax:770-922-0526
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045829207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000806737BMedicaid
GA000806737BMedicaid
GA05BDGZGMedicare ID - Type Unspecified