Provider Demographics
NPI:1275690604
Name:NORTHLAKE OBSTETRICS AND GYNECOLOGY, PC
Entity Type:Organization
Organization Name:NORTHLAKE OBSTETRICS AND GYNECOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:L
Authorized Official - Last Name:SOTOMAYOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-939-5102
Mailing Address - Street 1:3957 HOLCOMB BRIDGE RD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092
Mailing Address - Country:US
Mailing Address - Phone:770-939-5102
Mailing Address - Fax:770-938-9323
Practice Address - Street 1:3957 HOLCOMB BRIDGE RD.
Practice Address - Street 2:SUITE 100
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092
Practice Address - Country:US
Practice Address - Phone:770-939-5102
Practice Address - Fax:770-938-9323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300026901AMedicaid
GA11D0255917OtherCLIA WAIVER
GA300026901AMedicaid