Provider Demographics
NPI:1750328738
Name:WALRAVEN, JAMIE W (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:W
Last Name:WALRAVEN
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 1:105 GOVERNORS SQ
Mailing Address - Street 2:SUITE E
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-4866
Mailing Address - Country:US
Mailing Address - Phone:678-364-8414
Mailing Address - Fax:678-364-8446
Practice Address - Street 1:105 GOVERNORS SQ
Practice Address - Street 2:SUITE E
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-4866
Practice Address - Country:US
Practice Address - Phone:678-364-8414
Practice Address - Fax:678-364-8446
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045023207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000817022DMedicaid
GAG87453Medicare UPIN
GA000817022DMedicaid