Provider Demographics
NPI:1669602231
Name:GEORGE, TERESA KIZHAKETHALAKAL (MD)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:KIZHAKETHALAKAL
Last Name:GEORGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TERESA
Other - Middle Name:K
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:771 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4386
Mailing Address - Country:US
Mailing Address - Phone:770-670-6920
Mailing Address - Fax:770-670-6920
Practice Address - Street 1:771 OLD NORCROSS RD
Practice Address - Street 2:SUITE 120
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4386
Practice Address - Country:US
Practice Address - Phone:770-670-6920
Practice Address - Fax:770-670-6920
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.205568207R00000X
GA67420207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1894206Medicaid
GA003140814BMedicaid
LA1894206Medicaid