Healthcare Provider Details

I. General information

NPI: 1104265016
Provider Name (Legal Business Name): VERA LAFOSSE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 SOUTHCREST DR STE 200
STOCKBRIDGE GA
30281-6116
US

IV. Provider business mailing address

1035 SOUTHCREST DR STE 200
STOCKBRIDGE GA
30281-6116
US

V. Phone/Fax

Practice location:
  • Phone: 770-474-5302
  • Fax: 770-474-1275
Mailing address:
  • Phone: 404-836-0136
  • Fax: 404-850-8695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number006482
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number75308
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: