Provider Demographics
NPI:1104903814
Name:ATALLAH, CAMILLE (MD)
Entity type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:
Last Name:ATALLAH
Suffix:
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:PO BOX 1639
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1639
Mailing Address - Country:US
Mailing Address - Phone:912-871-7100
Mailing Address - Fax:912-871-7110
Practice Address - Street 1:1058 BERMUDA RUN ROAD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-871-7100
Practice Address - Fax:912-871-7110
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047289174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA020052432OtherRAILROAD MEDICARE
GA582449176OtherCEDAR SURGICAL ASSOCIATES
GA00827681BMedicaid
GA00827681BMedicaid
GA020052432OtherRAILROAD MEDICARE