Provider Demographics
NPI:1326031741
Name:SULTON, JACQUELINE R (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:R
Last Name:SULTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2258 NORTHLAKE PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4019
Mailing Address - Country:US
Mailing Address - Phone:770-670-6100
Mailing Address - Fax:470-359-5996
Practice Address - Street 1:2258 NORTHLAKE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4019
Practice Address - Country:US
Practice Address - Phone:770-670-6100
Practice Address - Fax:470-359-5996
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027675208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000307304DMedicaid