Healthcare Provider Details

I. General information

NPI: 1518927110
Provider Name (Legal Business Name): DIANE LEIGH WISEBRAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FERRY RD NE SUITE 820
ATLANTA GA
30342-1626
US

IV. Provider business mailing address

550 PEACHTREE ST NE SUITE 1600
ATLANTA GA
30308-2208
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-9307
  • Fax: 404-252-5839
Mailing address:
  • Phone: 404-881-1099
  • Fax: 404-874-1249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number022195
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: