Provider Demographics
NPI:1154613974
Name:JENNINGS, ERIC DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:DOUGLAS
Last Name:JENNINGS
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 1:800 MOUNT VERNON HWY NE STE 120
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4293
Mailing Address - Country:US
Mailing Address - Phone:770-804-1684
Mailing Address - Fax:770-804-1679
Practice Address - Street 1:800 MOUNT VERNON HWY NE STE 120
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4293
Practice Address - Country:US
Practice Address - Phone:770-804-1684
Practice Address - Fax:770-804-1679
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75745207W00000X
FLME123346207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014758600Medicaid
FLID770ZMedicare PIN