Provider Demographics
NPI:1962441493
Name:EUBANKS, AMY JORDAN (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:JORDAN
Last Name:EUBANKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:
Practice Address - Street 1:204 ALLEN MEMORIAL DR STE 201
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-2062
Practice Address - Country:US
Practice Address - Phone:770-537-6500
Practice Address - Fax:770-824-2600
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052922207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I11872Medicare UPIN