Provider Demographics
NPI:1730128638
Name:EYZAGUIRRE, WILLIAM A (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:EYZAGUIRRE
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:PO BOX 769609
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-8224
Mailing Address - Country:US
Mailing Address - Phone:770-730-5800
Mailing Address - Fax:770-730-5803
Practice Address - Street 1:5677 BUFORD HWY NE
Practice Address - Street 2:STE. 210
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30340-1244
Practice Address - Country:US
Practice Address - Phone:678-547-1045
Practice Address - Fax:678-547-1048
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014243208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000111966EMedicaid
GA000111966GMedicaid
GA000111966DMedicaid
GA000111966HMedicaid
GA000111966EMedicaid
GA000111966DMedicaid