=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659409043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENISE CHERYL DE VERANEZ MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 07/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4477 W VILLAGE PKWY
-----------------------------------------------------
City | ELLENWOOD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30294-2869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-366-9311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 285 COUNTRY CLUB DR SUITE 200
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-7350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-507-1414
-----------------------------------------------------
Fax | 770-507-5150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 041279
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------