Clarkston Primary & Urgent Care, LLC
Organization Active NPI Family Medicine Physician · Clarkston, GA
NPI 1043781420 · NPPES record last updated Dec 11, 2018
Key facts
- NPI
- 1043781420
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- CLARKSTON PRIMARY & URGENT CARE, LLC
- Practice address
- 4600 E Ponce de Leon Ave Ste a
Clarkston, GA 30021-1839 - Phone
- (770) 703-5408
- Fax
- (877) 779-5837
- NPI assigned
- Dec 11, 2018
- Organization subpart
- No
Authorized official
- Name
- Ms. Etsubdenke Areaya, FNP-C
- Title
- Authorized Official
- Phone
- (678) 763-2247
Practitioners 5
-
Mandana Rezaei-Amiri, M.D.
-
Fariba Sohrabi, DNP
-
Selamawit Mola, FNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in GA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20241102000245 | GA | Part B Supplier - Clinic/Group Practice | 9537401450 |
Receives reassigned benefits from 2 practitioners Practice locations: Clarkston, GA |
National Provider Directory
Locations
4600 E Ponce de Leon Ave
Ste A
Clarkston, GA 30021
Phone (678) 705-9685
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes |
Addresses
Primary practice location
4600 E Ponce de Leon Ave Ste a
Clarkston, GA 30021-1839
Mailing address
4600 E Ponce de Leon Ave Ste a
Clarkston, GA 30021-1839
Phone (770) 703-5408
Other names
- CLARKSTON PRIMARY & URGENT CARE LLC
Other providers in Clarkston, GA
- Huei-Chen Cheng
- Mariya George Cheriyampurathu
- Patrice Gibson Chishom
- Clarkston Community Health Center, Inc.
- Clarkston Family Medicine
- Marqueta A Coffer
- Corinthianhomwcareservices
- Kimberley Anne Crawford
- Casey C Cudmore
- Emily Howell Curia
All providers in Clarkston, GA · Family Medicine Physician in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 11, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.