Provider Demographics
NPI:1639396518
Name:DERISO, GEORGE T III (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:T
Last Name:DERISO
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SANDY PLAINS ROAD
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 HOSPITAL SOUTH DR
Practice Address - Street 2:SUITE 409
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6810
Practice Address - Country:US
Practice Address - Phone:770-424-6893
Practice Address - Fax:770-528-9938
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA047732207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000904208WMedicaid
GA000904208TMedicaid
GA000904208VMedicaid
GA000904208SMedicaid
GA000904208VMedicaid
H52381Medicare UPIN
GA000904208WMedicaid