Basic Information
| Provider Information | |||||||||
| NPI: | 1982674651 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENDER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | IVAN | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6335 HOSPITAL PKWY | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300971549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047788311 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6325 HOSPITAL PKWY | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300975775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047788311 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 84437 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100504134 | 05 | NV | MEDICAID |