Provider Demographics
NPI:1649310426
Name:HORSFORD, ALISA C (MD)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:C
Last Name:HORSFORD
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:PO BOX 3559
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-0993
Mailing Address - Country:US
Mailing Address - Phone:770-979-9996
Mailing Address - Fax:770-979-1202
Practice Address - Street 1:6335 HOSPITAL PKWY
Practice Address - Street 2:SUITE 313
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1549
Practice Address - Country:US
Practice Address - Phone:770-979-9996
Practice Address - Fax:770-979-1202
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063242207L00000X
390200000X
MDD0069966207L00000X
GA63242207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD418741500Medicaid
MDD0069966OtherMARYLAND LICENSE
GA063242OtherLICENSE
MDD0069966OtherMARYLAND LICENSE