Healthcare Provider Details

I. General information

NPI: 1235575325
Provider Name (Legal Business Name): GERARDO JULIAN SORACCO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4415 NORTHSIDE CHASE NW
ATLANTA GA
30327-3567
US

IV. Provider business mailing address

4415 NORTHSIDE CHASE NW
ATLANTA GA
30327-3567
US

V. Phone/Fax

Practice location:
  • Phone: 404-364-9017
  • Fax:
Mailing address:
  • Phone: 404-364-9017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number11193
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: