Provider Demographics
NPI:1982674651
Name:ENDER, JEFFREY IVAN (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:IVAN
Last Name:ENDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6335 HOSPITAL PKWY
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1549
Mailing Address - Country:US
Mailing Address - Phone:404-778-8311
Mailing Address - Fax:
Practice Address - Street 1:6325 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-5775
Practice Address - Country:US
Practice Address - Phone:404-778-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA84437207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100504134Medicaid
V104373Medicare PIN
NVV104373Medicare PIN
NVG36020Medicare UPIN
NV100504134Medicaid