Healthcare Provider Details

I. General information

NPI: 1720263742
Provider Name (Legal Business Name): GEORGIA PLASTIC SURGERY SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 PLEASANT HILL RD SUITE 460
DULUTH GA
30096-1407
US

IV. Provider business mailing address

3855 PLEASANT HILL RD SUITE 460
DULUTH GA
30096-1407
US

V. Phone/Fax

Practice location:
  • Phone: 770-418-1234
  • Fax: 770-817-1110
Mailing address:
  • Phone: 770-418-1234
  • Fax: 770-817-1110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number045060
License Number StateGA

VIII. Authorized Official

Name: DR. ROBERT MORGAN DAVOUDI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 770-418-1234