Provider Demographics
NPI:1922281104
Name:GEORGE, CLARISSA DAWN (RT (R) (CT))
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:DAWN
Last Name:GEORGE
Suffix:
Gender:F
Credentials:RT (R) (CT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 GROVEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-5952
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5810 WATERFALL WAY
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-1376
Practice Address - Country:US
Practice Address - Phone:407-448-6712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCRT 520132471C3401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography