Provider Demographics
NPI:1831132646
Name:YOUNGBLOOD, ELAINE C (MD)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:C
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:CAMILLE
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1045 SOUTHCREST DR
Mailing Address - Street 2:STE 110
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281
Mailing Address - Country:US
Mailing Address - Phone:770-507-2212
Mailing Address - Fax:770-507-2213
Practice Address - Street 1:1045 SOUTHCREST DR
Practice Address - Street 2:STE 110
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:770-507-2212
Practice Address - Fax:770-507-2213
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043513208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000756599CMedicaid
GA52671130OtherBCBS
GA000756599CMedicaid