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General NPI Number Information
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NPI Number | 1518236645
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Entity Type | Organization
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Legal Business Name | PRINCETON LAKES PEDIATRICS, LLC
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Dates
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Enumeration Date | 12/19/2011
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Last Update Date | 12/13/2023
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Provider Practice Location Address
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Address Line | 3885 PRINCETON LAKES WAY SW SUITE 302
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City | ATLANTA
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State | GA
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Zip | 30331-5589
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Country | US
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Telephone | 404-629-1880
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Fax | 404-629-1935
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Provider Business Mailing Address
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Address Line | 3885 PRINCETON LAKES WAY SW SUITE 302
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City | ATLANTA
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State | GA
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Zip | 30331-5589
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Country | US
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Telephone | 404-629-1880
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Fax | 404-629-1935
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Authorized Official
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Title or Position | OWNER
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Name | DEKISHA DRAYTON
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Credential | MD
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Telephone | 404-629-1880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 053016
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License Number State | GA
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