Facts
- Status
- A
- Credential
- MD
- Type
- Individual
- Enumeration date
- 2006-08-13
- Last updated
- 2025-03-31
Specialties
Licenses
- License LA
- MD15173R
- License GA
- 102672
Location
- Practice location
- 3950 AUSTELL RD
- City
- AUSTELL GA
- Postal code
- 301061121
- Phone
- 706-863-9595
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.