Provider Demographics
NPI:1366838815
Name:KISKADDON, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:KISKADDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 UPPER HEMBREE RD STE 103
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1230
Mailing Address - Country:US
Mailing Address - Phone:470-267-0410
Mailing Address - Fax:770-999-2710
Practice Address - Street 1:1360 UPPER HEMBREE RD STE 103
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1230
Practice Address - Country:US
Practice Address - Phone:470-267-0410
Practice Address - Fax:770-999-2710
Is Sole Proprietor?:No
Enumeration Date:2015-04-11
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA91642207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program