Provider Demographics
NPI:1780767665
Name:KALLAY, DANNETTE (MD)
Entity type:Individual
Prefix:MRS
First Name:DANNETTE
Middle Name:
Last Name:KALLAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 BOULEVARD SQ STE D
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-8022
Mailing Address - Country:US
Mailing Address - Phone:912-387-0445
Mailing Address - Fax:912-226-3513
Practice Address - Street 1:1701 BOULEVARD SQ STE D
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-8022
Practice Address - Country:US
Practice Address - Phone:912-387-0445
Practice Address - Fax:912-226-3513
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041044208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000758491EMedicaid