Provider Demographics
NPI:1962408930
Name:DAGNEW, ELIAS (MD)
Entity type:Individual
Prefix:DR
First Name:ELIAS
Middle Name:
Last Name:DAGNEW
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 1:11877 DOUGLAS RD
Mailing Address - Street 2:SUITE 102-272
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4325
Mailing Address - Country:US
Mailing Address - Phone:404-446-4424
Mailing Address - Fax:404-446-4420
Practice Address - Street 1:9635 VENTANA WAY STE 201
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-8622
Practice Address - Country:US
Practice Address - Phone:404-446-4424
Practice Address - Fax:404-446-4420
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054606207T00000X
FLME96941207T00000X
GAME96941207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA838984626AMedicaid
FL277245100Medicaid
GA14BDHJJMedicare PIN
FLAF018ZMedicare PIN
GA838984626AMedicaid