Provider Demographics
NPI:1659337442
Name:HALEY, DONNA CAROL (MD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:CAROL
Last Name:HALEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 MARIETTA HWY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2608
Mailing Address - Country:US
Mailing Address - Phone:770-479-8040
Mailing Address - Fax:770-479-7871
Practice Address - Street 1:687 MARIETTA HWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2608
Practice Address - Country:US
Practice Address - Phone:770-479-8040
Practice Address - Fax:770-479-7871
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040916207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
07/27/1959OtherDATE OF BIRTH
GAE23389Medicare UPIN
07/27/1959OtherDATE OF BIRTH