Healthcare Provider Details

I. General information

NPI: 1164930921
Provider Name (Legal Business Name): MIGUEL CERON SURGICAL ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2018
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE
ATLANTA GA
30308-2212
US

IV. Provider business mailing address

2630 NEWTON CT
CUMMING GA
30041-1958
US

V. Phone/Fax

Practice location:
  • Phone: 404-686-4411
  • Fax:
Mailing address:
  • Phone: 678-704-9294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: