Healthcare Provider Details

I. General information

NPI: 1851920573
Provider Name (Legal Business Name): KISHA LASHAUN BURGESS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WESTVIEW DR SW
ATLANTA GA
30310-1458
US

IV. Provider business mailing address

12470 SW 185TH ST
MIAMI FL
33177-3186
US

V. Phone/Fax

Practice location:
  • Phone: 404-756-1368
  • Fax: 404-756-1313
Mailing address:
  • Phone: 305-299-2508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number97697
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: