Provider Demographics
NPI:1851920573
Name:BURGESS, KISHA LASHAUN (DO)
Entity Type:Individual
Prefix:
First Name:KISHA
Middle Name:LASHAUN
Last Name:BURGESS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12470 SW 185TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-3186
Mailing Address - Country:US
Mailing Address - Phone:305-299-2508
Mailing Address - Fax:
Practice Address - Street 1:720 WESTVIEW DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1458
Practice Address - Country:US
Practice Address - Phone:404-756-1368
Practice Address - Fax:404-756-1313
Is Sole Proprietor?:No
Enumeration Date:2020-04-04
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA97697207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program