=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508343021
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANNETTE CHUA COCABO MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2018
-----------------------------------------------------
Last Update Date | 07/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 COLLINS DR STE B
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30120-8533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-607-0795
-----------------------------------------------------
Fax | 770-607-1339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127 ETOWAH DR
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30120-3701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-606-8095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 80898
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------