MEDICARE: DEKISHA PENDERGRASS DRAYTON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	053016	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306931548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEKISHA PENDERGRASS DRAYTON M.D.

Provider Business Mailing Address
First Line	:	6279 VININGS VINTAGE DR
Second Line	:
City	:	MABLETON
State	:	GA
Zip	:	30126-7202
Country	:	US
Telephone Number	:	404-394-6155
Fax Number	:

Provider Business Practice Location Address
First Line	:	3885 PRINCETON LAKES WAY
Second Line	:	SUITE 302
City	:	ATLANTA
State	:	GA
Zip	:	30331
Country	:	US
Telephone Number	:	404-629-1880
Fax Number	:	404-629-1935

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	09/08/2011

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