Healthcare Provider Details

I. General information

NPI: 1629390133
Provider Name (Legal Business Name): DOURRON WOMEN'S SPECIALIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 12/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 UPPER RIVERDALE RD SW SUITE B
RIVERDALE GA
30274-4945
US

IV. Provider business mailing address

253 UPPER RIVERDALE RD SW SUITE B
RIVERDALE GA
30274-4945
US

V. Phone/Fax

Practice location:
  • Phone: 678-381-1531
  • Fax: 678-990-3767
Mailing address:
  • Phone: 678-381-1531
  • Fax: 678-990-3767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number014308
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number014308
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number014308
License Number StateGA

VIII. Authorized Official

Name: DR. MARIA L DOURRON
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 678-381-1531