Basic Information
| Provider Information | |||||||||
| NPI: | 1780904896 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ILLSTON | ||||||||
| FirstName: | JANA | ||||||||
| MiddleName: | DOPSON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5780 PEACHTREE DUNWOODY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043038035 | ||||||||
| FaxNumber: | 4043031325 | ||||||||
| Practice Location | |||||||||
| Address1: | 11975 MORRIS RD STE 310 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300054444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707520824 | ||||||||
| FaxNumber: | 7707520845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2010 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 078039 | GA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VF0040X | 78039 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | GRP3569 | 01 | GA | MEDICARE | OTHER | 300034164A | 05 | GA | MEDICAID |