Provider Demographics
NPI:1790761799
Name:WELLONS, ERIC DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:DANIEL
Last Name:WELLONS
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 1:775 POPLAR RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-8300
Mailing Address - Country:US
Mailing Address - Phone:404-524-0095
Mailing Address - Fax:404-658-9558
Practice Address - Street 1:775 POPLAR RD
Practice Address - Street 2:SUITE 260
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8300
Practice Address - Country:US
Practice Address - Phone:404-524-0095
Practice Address - Fax:404-658-9558
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0491202086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00944347AMedicaid
GAH57383Medicare UPIN
GA77BBBJWMedicare ID - Type Unspecified