Healthcare Provider Details

I. General information

NPI: 1376021642
Provider Name (Legal Business Name): PAULINA CRUZ-VENEGAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 RALPH DAVID ABERNATHY BLVD SW
ATLANTA GA
30310-1649
US

IV. Provider business mailing address

1325 RALPH DAVID ABERNATHY BLVD SW
ATLANTA GA
30310-1649
US

V. Phone/Fax

Practice location:
  • Phone: 404-836-0136
  • Fax: 404-850-8695
Mailing address:
  • Phone: 404-836-0136
  • Fax: 404-850-8695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number21037
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number92449
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: