Healthcare Provider Details

I. General information

NPI: 1124046990
Provider Name (Legal Business Name): PLASTIKOS PLASTIC AND RECONSTRUCTIVE SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4370 GEORGETOWN SQ
ATLANTA GA
30338-6205
US

IV. Provider business mailing address

4370 GEORGETOWN SQ
ATLANTA GA
30338-6205
US

V. Phone/Fax

Practice location:
  • Phone: 770-457-4677
  • Fax: 770-457-4428
Mailing address:
  • Phone: 770-457-4677
  • Fax: 770-457-4428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number31272
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number31272
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPOD001047
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001047
License Number StateGA

VIII. Authorized Official

Name: DR. SUSAN KOLB
Title or Position: OWNER/PLASTIC SURGEON
Credential: M.D.
Phone: 770-457-4677