Provider Demographics
NPI:1629075544
Name:CALLAWAY, JUAQUITA D (MD)
Entity Type:Individual
Prefix:MS
First Name:JUAQUITA
Middle Name:D
Last Name:CALLAWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 LAWRENCEVILLE HWY
Mailing Address - Street 2:STE 107
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033
Mailing Address - Country:US
Mailing Address - Phone:678-205-0405
Mailing Address - Fax:
Practice Address - Street 1:2785 LAWRENCEVILLE HWY
Practice Address - Street 2:STE 107
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:678-205-0405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2013-06-07
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
GA033289207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000532749AMedicaid
GA16BDGBQMedicare ID - Type Unspecified
GAG54454Medicare UPIN