Provider Demographics
NPI:1063595973
Name:KALLAY, EUGENE WYNN (MD)
Entity type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:WYNN
Last Name:KALLAY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1701 BOULEVARD SQ
Mailing Address - Street 2:D
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-8021
Mailing Address - Country:US
Mailing Address - Phone:912-387-0445
Mailing Address - Fax:912-226-3513
Practice Address - Street 1:1701 BOULEVARD SQ
Practice Address - Street 2:D
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-8021
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:2014-11-17
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Provider Licenses
StateLicense IDTaxonomies
GA027395208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000311638IMedicaid
GA000311638CMedicaid