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General NPI Number Information
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NPI Number | 1932300084
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Entity Type | Organization
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Legal Business Name | ATLANTA DERMATOLOGY & SURGERY P.A.
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Dates
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Enumeration Date | 05/29/2007
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Last Update Date | 11/17/2015
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Provider Practice Location Address
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Address Line | 1462 MONTREAL RD SUITE 411
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City | TUCKER
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State | GA
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Zip | 30084-6929
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Country | US
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Telephone | 404-296-8000
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Fax | 770-493-6842
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Provider Business Mailing Address
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Address Line | 1462 MONTREAL RD SUITE 411
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City | TUCKER
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State | GA
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Zip | 30084-6929
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Country | US
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Telephone | 404-296-8000
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Fax | 770-493-6842
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JERRY LEE COOPER
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Credential | MD
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Telephone | 404-296-8000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 011850
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License Number State | GA
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