Provider Demographics
NPI:1124046990
Name:PLASTIKOS PLASTIC AND RECONSTRUCTIVE SURGERY
Entity type:Organization
Organization Name:PLASTIKOS PLASTIC AND RECONSTRUCTIVE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PLASTIC SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-457-4677
Mailing Address - Street 1:4370 GEORGETOWN SQ
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6205
Mailing Address - Country:US
Mailing Address - Phone:770-457-4677
Mailing Address - Fax:770-457-4428
Practice Address - Street 1:4370 GEORGETOWN SQ
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6205
Practice Address - Country:US
Practice Address - Phone:770-457-4677
Practice Address - Fax:770-457-4428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA312722082S0105X, 208200000X
GAPOD001047213ES0103X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2514Medicare PIN