Provider Demographics
NPI:1376625087
Name:EARLE, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:EARLE
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 1:251 CROFT ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3863
Mailing Address - Country:US
Mailing Address - Phone:770-834-7117
Mailing Address - Fax:
Practice Address - Street 1:251 CROFT ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3863
Practice Address - Country:US
Practice Address - Phone:770-834-7117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2015-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032723207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00436488AMedicaid
GAC78743Medicare UPIN
GA08BDCJSMedicare ID - Type Unspecified