Provider Demographics
NPI:1629286745
Name:ANDERSON, KEISA G (MD)
Entity Type:Individual
Prefix:
First Name:KEISA
Middle Name:G
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KEISA
Other - Middle Name:J
Other - Last Name:GODWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5780 PEACHTREE DUNWOODY ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1513
Mailing Address - Country:US
Mailing Address - Phone:404-303-1224
Mailing Address - Fax:404-303-1325
Practice Address - Street 1:5780 PEACHTREE DUNWOODY ROAD
Practice Address - Street 2:SUITE 295
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1544
Practice Address - Country:US
Practice Address - Phone:404-255-0621
Practice Address - Fax:404-252-0822
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59159207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA688965242DMedicaid
GA688965242EMedicaid
GA688965242GMedicaid
GA688965242GMedicaid