Provider Demographics
NPI:1780904896
Name:ILLSTON, JANA DOPSON (MD)
Entity type:Individual
Prefix:
First Name:JANA
Middle Name:DOPSON
Last Name:ILLSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5780 PEACHTREE DUNWOODY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1513
Mailing Address - Country:US
Mailing Address - Phone:404-303-8035
Mailing Address - Fax:404-303-1325
Practice Address - Street 1:11975 MORRIS RD STE 310
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4444
Practice Address - Country:US
Practice Address - Phone:770-752-0824
Practice Address - Fax:770-752-0845
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-11
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA078039207VG0400X
GA78039207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3569OtherMEDICARE
GA300034164AMedicaid