Provider Demographics
NPI:1053555870
Name:WERAGODA, FARESA Z (MD)
Entity type:Individual
Prefix:
First Name:FARESA
Middle Name:Z
Last Name:WERAGODA
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 1:5670 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:STE 8810
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1699
Mailing Address - Country:US
Mailing Address - Phone:404-256-2525
Mailing Address - Fax:404-845-4720
Practice Address - Street 1:4800 OLDE TOWNE PKWY STE 420
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4424
Practice Address - Country:US
Practice Address - Phone:404-256-2525
Practice Address - Fax:404-845-4720
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066682207R00000X, 207RC0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003162066BMedicaid
GA003162066CMedicaid
GA003162066AMedicaid
GA003162066AMedicaid