Provider Demographics
NPI:1154318004
Name:CAMPBELL, ELEANOR WALAITIS (DO)
Entity type:Individual
Prefix:
First Name:ELEANOR
Middle Name:WALAITIS
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:J
Other - Last Name:WALAITIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3925 JOHNS CREEK CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1265
Mailing Address - Country:US
Mailing Address - Phone:678-474-4742
Mailing Address - Fax:678-474-0095
Practice Address - Street 1:3925 JOHNS CREEK CT
Practice Address - Street 2:SUITE A
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1265
Practice Address - Country:US
Practice Address - Phone:678-474-4742
Practice Address - Fax:678-474-0095
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GABW2511120OtherDEA NUMBER
GABW2511120OtherDEA NUMBER