Healthcare Provider Details

I. General information

NPI: 1588022438
Provider Name (Legal Business Name): GWINNETT FAMILY MEDICINE AND GERIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2016
Last Update Date: 02/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 GRAYSON HWY SUITE 215
LAWRENCEVILLE GA
30046-5736
US

IV. Provider business mailing address

706 GRAYSON HWY SUITE 215
LAWRENCEVILLE GA
30046-5736
US

V. Phone/Fax

Practice location:
  • Phone: 770-316-2994
  • Fax:
Mailing address:
  • Phone: 770-316-2994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number11080875
License Number StateGA

VIII. Authorized Official

Name: WEZYANN GAYLE
Title or Position: CEO/OWNER
Credential: M.D.
Phone: 646-642-1564