Healthcare Provider Details

I. General information

NPI: 1912971649
Provider Name (Legal Business Name): ERIC VERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 02/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 PERMIAN WAY SUITE A
VILLA RICA GA
30180-3252
US

IV. Provider business mailing address

PO BOX 1615
VILLA RICA GA
30180-6409
US

V. Phone/Fax

Practice location:
  • Phone: 770-771-5235
  • Fax: 770-771-5236
Mailing address:
  • Phone: 770-771-5235
  • Fax: 770-771-5236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number052389
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: