Provider Demographics
NPI:1154491165
Name:WHEATLEY, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WHEATLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 UPPER HEMBREE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076
Mailing Address - Country:US
Mailing Address - Phone:770-442-8100
Mailing Address - Fax:770-664-8298
Practice Address - Street 1:1250 UPPER HEMBREE RD.
Practice Address - Street 2:SUITE B
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:770-442-8100
Practice Address - Fax:770-664-8298
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031357207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00468795AMedicaid
GA00468795AMedicaid
16BDBVHMedicare ID - Type Unspecified