Provider Demographics
NPI:1396736815
Name:DOLORES, EFFIE S (MD)
Entity type:Individual
Prefix:DR
First Name:EFFIE
Middle Name:S
Last Name:DOLORES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EFFIE
Other - Middle Name:S
Other - Last Name:DOLORES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4485 TENCH RD
Mailing Address - Street 2:STE 630
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6740
Mailing Address - Country:US
Mailing Address - Phone:770-904-5252
Mailing Address - Fax:
Practice Address - Street 1:4485 TENCH RD
Practice Address - Street 2:STE 630
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6740
Practice Address - Country:US
Practice Address - Phone:770-904-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043598208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000746281EMedicaid
GA309852302AMedicaid