Provider Demographics
NPI:1588022438
Name:GWINNETT FAMILY MEDICINE AND GERIATRICS
Entity Type:Organization
Organization Name:GWINNETT FAMILY MEDICINE AND GERIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WEZYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-642-1564
Mailing Address - Street 1:706 GRAYSON HWY
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5736
Mailing Address - Country:US
Mailing Address - Phone:770-316-2994
Mailing Address - Fax:
Practice Address - Street 1:706 GRAYSON HWY
Practice Address - Street 2:SUITE 215
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5736
Practice Address - Country:US
Practice Address - Phone:770-316-2994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11080875261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care