Healthcare Provider Details

I. General information

NPI: 1710976048
Provider Name (Legal Business Name): LASONYA ROBERTS-LOPEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 HOSPITAL SOUTH DR SUITE 102
AUSTELL GA
30106-6810
US

IV. Provider business mailing address

1700 HOSPITAL SOUTH DR SUITE 102
AUSTELL GA
30106-6810
US

V. Phone/Fax

Practice location:
  • Phone: 770-792-6262
  • Fax:
Mailing address:
  • Phone: 770-792-6262
  • Fax: 678-398-1929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number52818
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number052818
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: