Provider Demographics
NPI:1457886780
Name:KASSA, WODERYELESH (MD)
Entity type:Individual
Prefix:DR
First Name:WODERYELESH
Middle Name:
Last Name:KASSA
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 1:3825 MEDICAL PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6831
Mailing Address - Country:US
Mailing Address - Phone:770-948-5578
Mailing Address - Fax:
Practice Address - Street 1:3825 MEDICAL PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6831
Practice Address - Country:US
Practice Address - Phone:770-948-5578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA95343207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program