Basic Information
| Provider Information | |||||||||
| NPI: | 1871583609 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLEBY | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 CIRCLE 75 PKWY. | ||||||||
| Address2: | STE. 900 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303393084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703840284 | ||||||||
| FaxNumber: | 4044461957 | ||||||||
| Practice Location | |||||||||
| Address1: | 3825 MEDICAL PARK DR. | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301066831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707455101 | ||||||||
| FaxNumber: | 7707459740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 000433 | GA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | POD000433 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 000138993A | 05 | GA | MEDICAID | 1756385 | 05 | LA | MEDICAID |