1659409043 NPI number — DR. DENISE CHERYL DE VERANEZ MD

Table of content: DR. DENISE CHERYL DE VERANEZ MD (NPI 1659409043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659409043 NPI number — DR. DENISE CHERYL DE VERANEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE VERANEZ
Provider First Name:
DENISE
Provider Middle Name:
CHERYL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659409043
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
285 COUNTRY CLUB DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
STOCKBRIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30281-7350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-507-1414
Provider Business Mailing Address Fax Number:
770-507-5150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4477 W VILLAGE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLENWOOD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30294-2869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-366-9311
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  041279 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00710575E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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