Provider Demographics
NPI:1922187871
Name:HAIRSTON, JAHMAL A (MD)
Entity Type:Individual
Prefix:DR
First Name:JAHMAL
Middle Name:A
Last Name:HAIRSTON
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 1:6130 PRESTLEY MILL RD STE C
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2288
Mailing Address - Country:US
Mailing Address - Phone:678-838-3903
Mailing Address - Fax:678-838-7454
Practice Address - Street 1:6130 PRESTLEY MILL RD STE C
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2288
Practice Address - Country:US
Practice Address - Phone:678-838-3903
Practice Address - Fax:678-838-7454
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056293207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00310275Medicaid
GAI28843Medicare UPIN
GAP00310275Medicaid