Provider Demographics
NPI:1720407588
Name:CUELLO PICHARDO, KILSY (MD)
Entity Type:Individual
Prefix:
First Name:KILSY
Middle Name:
Last Name:CUELLO PICHARDO
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 1:157 CLINIC AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4454
Mailing Address - Country:US
Mailing Address - Phone:770-832-0429
Mailing Address - Fax:770-838-9108
Practice Address - Street 1:157 CLINIC AVE STE 203
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4454
Practice Address - Country:US
Practice Address - Phone:770-832-0429
Practice Address - Fax:770-838-9108
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA77453207R00000X, 207RN0300X
PR030553-R208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003164765BMedicaid