Provider Demographics
NPI:1235130626
Name:SERRAVEZZA, KIMBERLY A (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:SERRAVEZZA
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 1:4 EXECUTIVE PARK EAST NE
Mailing Address - Street 2:SUITE 470
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2245
Mailing Address - Country:US
Mailing Address - Phone:404-327-9682
Mailing Address - Fax:
Practice Address - Street 1:4 EXECUTIVE PARK EAST NE
Practice Address - Street 2:SUITE 470
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2245
Practice Address - Country:US
Practice Address - Phone:404-327-9682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0520482084S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0010XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
26BDJWHMedicare ID - Type Unspecified