Provider Demographics
NPI:1104820125
Name:BARON, MICHAEL LESLEY (DO)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LESLEY
Last Name:BARON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1505 LILBURN STONE MTN RD
Mailing Address - Street 2:STE 100
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-1857
Mailing Address - Country:US
Mailing Address - Phone:770-469-1711
Mailing Address - Fax:770-469-1837
Practice Address - Street 1:1505 LILBURN STONE MTN RD
Practice Address - Street 2:STE 100
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-1857
Practice Address - Country:US
Practice Address - Phone:770-469-1711
Practice Address - Fax:770-469-1837
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0033273207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00474779RMedicaid
Q8LCBDRMedicare ID - Type Unspecified
GA00474779RMedicaid