Healthcare Provider Details

I. General information

NPI: 1104821917
Provider Name (Legal Business Name): JONATHAN BARAK FASS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 COWLES CLINIC WAY STE 100
GREENSBORO GA
30642-5285
US

IV. Provider business mailing address

1180 RESURGENCE DR STE 100
WATKINSVILLE GA
30677-7211
US

V. Phone/Fax

Practice location:
  • Phone: 706-543-5858
  • Fax: 706-543-2050
Mailing address:
  • Phone: 706-543-5858
  • Fax: 706-543-2050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number046089
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: