Provider Demographics
NPI:1700047784
Name:BASHAN-GILZENRAT, KEREN AVIVA (MD)
Entity Type:Individual
Prefix:DR
First Name:KEREN
Middle Name:AVIVA
Last Name:BASHAN-GILZENRAT
Suffix:
Gender:F
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 1:55 WHITCHER ST NE STE 130
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-426-1629
Practice Address - Fax:770-427-8001
Is Sole Proprietor?:No
Enumeration Date:2008-06-22
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-01249390200000X
390200000X
GA0700452086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program