Provider Demographics
NPI:1992025803
Name:DONALD, ERIC LAROY
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:LAROY
Last Name:DONALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 WESTOVER AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6333
Mailing Address - Country:US
Mailing Address - Phone:229-403-2456
Mailing Address - Fax:
Practice Address - Street 1:716 WESTOVER AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6333
Practice Address - Country:US
Practice Address - Phone:229-403-2456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL691097196172V00000X
FL691097198172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691097196Medicaid
FL691097198Medicaid