Healthcare Provider Details

I. General information

NPI: 1831500370
Provider Name (Legal Business Name): GRAYSON PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

297 COOPER RD
LOGANVILLE GA
30052-2518
US

IV. Provider business mailing address

297 COOPER RD
LOGANVILLE GA
30052-2518
US

V. Phone/Fax

Practice location:
  • Phone: 678-381-2630
  • Fax: 678-381-2627
Mailing address:
  • Phone: 678-381-2630
  • Fax: 678-381-2627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number057218
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN154025
License Number StateGA

VIII. Authorized Official

Name: JULIE A OPEKA
Title or Position: NP, CFO
Credential: CPNP
Phone: 678-381-2630