Provider Demographics
NPI:1639100480
Name:DONOHUE, JEFFREY ALLEN
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALLEN
Last Name:DONOHUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3755 SIXES RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-7842
Mailing Address - Country:US
Mailing Address - Phone:770-720-1880
Mailing Address - Fax:770-704-7162
Practice Address - Street 1:3755 SIXES RD
Practice Address - Street 2:SUITE 202
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-7842
Practice Address - Country:US
Practice Address - Phone:770-720-1880
Practice Address - Fax:770-704-7162
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF57460Medicare UPIN
GA08BBTLPMedicare ID - Type Unspecified