Provider Demographics
NPI:1720193634
Name:CHASTAIN, SUSAN W (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:W
Last Name:CHASTAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:WHITE
Other - Last Name:CHASTAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11 DUNWOODY PARK
Mailing Address - Street 2:STE 190
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338
Mailing Address - Country:US
Mailing Address - Phone:770-392-6555
Mailing Address - Fax:770-392-6550
Practice Address - Street 1:11 DUNWOODY PARK
Practice Address - Street 2:STE 190
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338
Practice Address - Country:US
Practice Address - Phone:770-392-6555
Practice Address - Fax:770-392-6550
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055188208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics