Provider Demographics
NPI:1427163344
Name:SELPH, DONALD ANTHONY JR (MD FACP)
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:ANTHONY
Last Name:SELPH
Suffix:JR
Gender:M
Credentials:MD FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 PLAZA AVENUE
Mailing Address - Street 2:SUITE D
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023
Mailing Address - Country:US
Mailing Address - Phone:478-374-5544
Mailing Address - Fax:478-374-0608
Practice Address - Street 1:911 PLAZA AVENUE
Practice Address - Street 2:SUITE D
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023
Practice Address - Country:US
Practice Address - Phone:478-374-5544
Practice Address - Fax:478-374-0608
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042117207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00795165AMedicaid
GA11BDPFQMedicare ID - Type Unspecified
GA00795165AMedicaid