Provider Demographics
NPI:1700023330
Name:JEANNOT, MICHEL
Entity Type:Individual
Prefix:
First Name:MICHEL
Middle Name:
Last Name:JEANNOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHEL
Other - Middle Name:
Other - Last Name:JEANNOT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:101 TARA COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8018
Mailing Address - Country:US
Mailing Address - Phone:678-928-9700
Mailing Address - Fax:770-466-1585
Practice Address - Street 1:101 TARA COMMONS DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8018
Practice Address - Country:US
Practice Address - Phone:678-928-9700
Practice Address - Fax:770-466-1585
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200901094207RP1001X
GA065686207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109685AMedicaid