Healthcare Provider Details

I. General information

NPI: 1871089367
Provider Name (Legal Business Name): KHEMAPORN LERTDETKAJORN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2018
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 UPPER RIVERDALE RD SW STE 111
RIVERDALE GA
30274-2642
US

IV. Provider business mailing address

33 UPPER RIVERDALE RD SW STE 111
RIVERDALE GA
30274-2642
US

V. Phone/Fax

Practice location:
  • Phone: 770-909-2045
  • Fax: 770-909-2056
Mailing address:
  • Phone: 770-909-2045
  • Fax: 770-909-2056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number100193
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: