Healthcare Provider Details

I. General information

NPI: 1508050154
Provider Name (Legal Business Name): GERSON ESCONDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 WATER OAK DR
CEDARTOWN GA
30125-2095
US

IV. Provider business mailing address

1401 BURLEYSON DR SUITE 4
DALTON GA
30720-2522
US

V. Phone/Fax

Practice location:
  • Phone: 770-748-0030
  • Fax:
Mailing address:
  • Phone: 706-270-5002
  • Fax: 706-270-5002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number018643
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: