Provider Demographics
NPI:1063407377
Name:RILEY, DINEE MONIQUE (MD)
Entity type:Individual
Prefix:MISS
First Name:DINEE
Middle Name:MONIQUE
Last Name:RILEY
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 1:1525 BUFORD HWY
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3665
Mailing Address - Country:US
Mailing Address - Phone:770-945-1699
Mailing Address - Fax:770-945-1698
Practice Address - Street 1:1525 BUFORD HWY
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3665
Practice Address - Country:US
Practice Address - Phone:770-945-1699
Practice Address - Fax:770-945-1698
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054502207R00000X
GA54502207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA600254685AMedicaid
GA600254685AMedicaid
GA11SCDNDMedicare ID - Type Unspecified