Provider Demographics
NPI:1649316464
Name:RISTIC, IRENE (MD)
Entity type:Individual
Prefix:MS
First Name:IRENE
Middle Name:
Last Name:RISTIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:IRENA
Other - Middle Name:
Other - Last Name:RISTIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:225 MAYFIELD FARMS DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6161
Mailing Address - Country:US
Mailing Address - Phone:770-271-2654
Mailing Address - Fax:
Practice Address - Street 1:902 ATHENS HWY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4904
Practice Address - Country:US
Practice Address - Phone:770-554-5533
Practice Address - Fax:770-554-8129
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037660207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00572448BMedicaid
GA00572448BMedicaid
GA93BDFRQMedicare ID - Type Unspecified