Provider Demographics
NPI:1831157072
Name:CHRISTIE, DONOVAN WAYNE SR (MD)
Entity type:Individual
Prefix:
First Name:DONOVAN
Middle Name:WAYNE
Last Name:CHRISTIE
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4514 CHAMBLEE DUNWOODY RD
Mailing Address - Street 2:SUITE 328
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6202
Mailing Address - Country:US
Mailing Address - Phone:678-205-2039
Mailing Address - Fax:678-205-2040
Practice Address - Street 1:2227 IDLEWOOD RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4827
Practice Address - Country:US
Practice Address - Phone:678-205-2039
Practice Address - Fax:678-205-2040
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044432208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00845798KMedicaid
GA000845798HMedicaid
GA000845798PMedicaid
GA00845798KMedicaid