Provider Demographics
NPI:1144226135
Name:DICRISTINA, MICHAEL ANGEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANGEL
Last Name:DICRISTINA
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 1:33 UPPER RIVERDALE RD SW
Mailing Address - Street 2:SUITE #21
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2626
Mailing Address - Country:US
Mailing Address - Phone:770-968-7933
Mailing Address - Fax:770-968-6521
Practice Address - Street 1:33 UPPER RIVERDALE RD SW
Practice Address - Street 2:SUITE 21
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2626
Practice Address - Country:US
Practice Address - Phone:770-968-7933
Practice Address - Fax:770-968-6521
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2015-06-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
GA022223207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000221328EMedicaid
GAD29297Medicare UPIN
GA000221328EMedicaid