Provider Demographics
NPI:1215159249
Name:SO, SUMI G (MD)
Entity type:Individual
Prefix:
First Name:SUMI
Middle Name:G
Last Name:SO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 3293
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3293
Mailing Address - Country:US
Mailing Address - Phone:317-614-9863
Mailing Address - Fax:844-876-0873
Practice Address - Street 1:743 SPRING ST NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3715
Practice Address - Country:US
Practice Address - Phone:800-562-4530
Practice Address - Fax:706-378-8864
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA059024207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA750216486AMedicaid
GA22BDDZRMedicare PIN