Individual
GEORGE T DERISO III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1700 HOSPITAL SOUTH DR, SUITE 409, AUSTELL, GA 30106-6810
(770) 424-6893
(770) 528-9938
Mailing address
805 SANDY PLAINS ROAD, MEDICAL STAFF SERVICES, MARIETTA, GA 30066-6340
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
Primary
047732
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000904208S
—
GA
05
—
000904208T
—
GA
05
—
000904208V
—
GA
05
—
000904208W
—
GA
Enumeration date
04/20/2007
Last updated
10/29/2019
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