Provider Demographics
NPI:1700205879
Name:DORTCH, ELYCEIA MONA (MD)
Entity Type:Individual
Prefix:DR
First Name:ELYCEIA
Middle Name:MONA
Last Name:DORTCH
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 1:60 11TH ST NE APT 714
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-4362
Mailing Address - Country:US
Mailing Address - Phone:404-444-5634
Mailing Address - Fax:
Practice Address - Street 1:2525 CUMBERLAND PKWY SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-3915
Practice Address - Country:US
Practice Address - Phone:470-698-0239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA80280207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program