Provider Demographics
NPI:1417905878
Name:MONTANA, SUZANA MARA (MD)
Entity Type:Individual
Prefix:
First Name:SUZANA
Middle Name:MARA
Last Name:MONTANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3780 HOLCOMB BRIDGE RD
Mailing Address - Street 2:STE C
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2701
Mailing Address - Country:US
Mailing Address - Phone:770-263-9101
Mailing Address - Fax:770-263-9102
Practice Address - Street 1:3780 HOLCOMB BRIDGE RD
Practice Address - Street 2:STE C
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-2701
Practice Address - Country:US
Practice Address - Phone:770-263-9101
Practice Address - Fax:770-263-9102
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA045097208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000773209UMedicaid
GA511L370126Medicare PIN