Provider Demographics
NPI:1346242229
Name:STAVISS, SUSAN GAIL (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAIL
Last Name:STAVISS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3939 ROSWELL RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6251
Mailing Address - Country:US
Mailing Address - Phone:770-578-2868
Mailing Address - Fax:770-971-8499
Practice Address - Street 1:3939 ROSWELL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6251
Practice Address - Country:US
Practice Address - Phone:770-578-2868
Practice Address - Fax:770-971-8499
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0386522080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000607703DMedicaid
GA241020OtherPRIVATE HEALTHCARE SYSTEM
GA4508167OtherAETNA USHEALTHCARE
GA3308662027OtherCIGNA