Provider Demographics
NPI:1063510311
Name:GERSON, EDWIN STEVEN (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:STEVEN
Last Name:GERSON
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 1:5664 RIVER OAKS PL NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-4256
Mailing Address - Country:US
Mailing Address - Phone:404-252-9729
Mailing Address - Fax:
Practice Address - Street 1:5664 RIVER OAKS PL NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-4256
Practice Address - Country:US
Practice Address - Phone:404-252-9729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0154692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000212022BMedicaid
GA30CDBMN GRP621Medicare ID - Type Unspecified
GA000212022BMedicaid