Provider Demographics
NPI:1336297936
Name:FASS, LEROY (MD)
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:
Last Name:FASS
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 1:1472 WEMBLEY CT NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3968
Mailing Address - Country:US
Mailing Address - Phone:404-321-6250
Mailing Address - Fax:
Practice Address - Street 1:1472 WEMBLEY CT NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3968
Practice Address - Country:US
Practice Address - Phone:404-321-6250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052501174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist