Provider Demographics
NPI:1104000660
Name:CLARA M PICAYO MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CLARA M PICAYO MD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PICAYO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-926-2757
Mailing Address - Street 1:5570 BELLS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-2526
Mailing Address - Country:US
Mailing Address - Phone:770-926-2757
Mailing Address - Fax:770-926-2758
Practice Address - Street 1:5570 BELLS FERRY RD
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-2526
Practice Address - Country:US
Practice Address - Phone:770-926-2757
Practice Address - Fax:770-926-2758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058381208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA608406833BMedicaid
GA01149193OtherAMERIGROUP