Provider Demographics
NPI:1053494278
Name:AYERTEY, KODJO (MD)
Entity Type:Individual
Prefix:
First Name:KODJO
Middle Name:
Last Name:AYERTEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 COLLIER RD NW
Mailing Address - Street 2:SUITE 635
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1613
Mailing Address - Country:US
Mailing Address - Phone:404-367-3014
Mailing Address - Fax:404-367-3558
Practice Address - Street 1:35 COLLIER RD NW
Practice Address - Street 2:STE 635
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1613
Practice Address - Country:US
Practice Address - Phone:404-367-3014
Practice Address - Fax:404-367-3558
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056513208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAI39211Medicare UPIN
GA11SCFKHOtherMEDICARE
GA588861180AMedicaid
GAP00381105OtherMEDICARE RAIL ROAD