Healthcare Provider Details

I. General information

NPI: 1689607269
Provider Name (Legal Business Name): RENATO CHAVES SOUZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 SENOIA RD
FAIRBURN GA
30213-1536
US

IV. Provider business mailing address

204 SENOIA RD
FAIRBURN GA
30213-1536
US

V. Phone/Fax

Practice location:
  • Phone: 770-964-9759
  • Fax: 770-964-7001
Mailing address:
  • Phone: 770-964-9759
  • Fax: 770-964-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number015826
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: