Healthcare Provider Details

I. General information

NPI: 1679658702
Provider Name (Legal Business Name): GWINNETT INFECTIOUS DISEASES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 RIVERSIDE PKWY SUITE 101
LAWRENCEVILLE GA
30043-5945
US

IV. Provider business mailing address

1960 RIVERSIDE PKWY SUITE 101
LAWRENCEVILLE GA
30043-5945
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-0466
  • Fax: 770-995-0472
Mailing address:
  • Phone: 770-995-0466
  • Fax: 770-995-0472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ELLIOT G RAIZES
Title or Position: PRESIDENT
Credential: MD
Phone: 770-995-0466