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General NPI Number Information
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NPI Number | 1649316464
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Entity Type | Individual
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Provider Name | IRENE RISTIC MD
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Gender | Female
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Dates
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Enumeration Date | 01/29/2007
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Last Update Date | 05/30/2012
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Provider Practice Location Address
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Address Line | 902 ATHENS HWY
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City | LOGANVILLE
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State | GA
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Zip | 30052-4904
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Country | US
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Telephone | 770-554-5533
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Fax | 770-554-8129
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Provider Business Mailing Address
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Address Line | 225 MAYFIELD FARMS DR
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-6161
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Country | US
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Telephone | 770-271-2654
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 037660
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License Number State | GA
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