Provider Demographics
NPI:1912228941
Name:EBNER, CHARLOTTE AMELIA (DO)
Entity type:Individual
Prefix:MISS
First Name:CHARLOTTE
Middle Name:AMELIA
Last Name:EBNER
Suffix:
Gender:F
Credentials:DO
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Other - Credentials:
Mailing Address - Street 1:2878 FIVE FORKS TRICKUM ROAD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044
Mailing Address - Country:US
Mailing Address - Phone:678-344-8700
Mailing Address - Fax:678-344-8600
Practice Address - Street 1:2878 FIVE FORKS TRICKUM RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5896
Practice Address - Country:US
Practice Address - Phone:678-344-8700
Practice Address - Fax:678-344-8600
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA069580207Q00000X
SC1390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP01117581OtherRAILROAD MEDICARE
SC013906Medicaid
SCP01117581OtherRAILROAD MEDICARE
SCAA8746067Medicare PIN