Healthcare Provider Details

I. General information

NPI: 1285612168
Provider Name (Legal Business Name): JORGE PEDRO LEGUIZAMO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 DULUTH HWY SUITE 201
LAWRENCEVILLE GA
30045-7695
US

IV. Provider business mailing address

1835 SAVOY DR STE 203
ATLANTA GA
30341-1073
US

V. Phone/Fax

Practice location:
  • Phone: 770-822-0788
  • Fax: 770-822-0326
Mailing address:
  • Phone: 770-822-0788
  • Fax: 770-822-0326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number061479
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: