Provider Demographics
NPI:1689671372
Name:NEISES, KERRY A (MD)
Entity type:Individual
Prefix:DR
First Name:KERRY
Middle Name:A
Last Name:NEISES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 VISTA DRIVE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721-8654
Mailing Address - Country:US
Mailing Address - Phone:706-226-3139
Mailing Address - Fax:706-278-6606
Practice Address - Street 1:914 VISTA DRIVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-8654
Practice Address - Country:US
Practice Address - Phone:706-226-3139
Practice Address - Fax:706-278-6606
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA43720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000755532BMedicaid
GA08BDBCQMedicare ID - Type Unspecified
GAG58423Medicare UPIN