Provider Demographics
NPI:1083664288
Name:FORMAN BLITZER, PENNY M (MD)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:M
Last Name:FORMAN BLITZER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4190 FALLS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8490
Mailing Address - Country:US
Mailing Address - Phone:770-674-2585
Mailing Address - Fax:770-476-1674
Practice Address - Street 1:4310 JOHNS CREEK PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6091
Practice Address - Country:US
Practice Address - Phone:770-476-4020
Practice Address - Fax:770-476-1674
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0050077208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics