Provider Demographics
NPI:1285612168
Name:LEGUIZAMO, JORGE PEDRO (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:PEDRO
Last Name:LEGUIZAMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 203
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1073
Mailing Address - Country:US
Mailing Address - Phone:770-822-0788
Mailing Address - Fax:770-822-0326
Practice Address - Street 1:698 DULUTH HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-7695
Practice Address - Country:US
Practice Address - Phone:770-822-0788
Practice Address - Fax:770-822-0326
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA061479207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA624397991DMedicaid
GA624397991EMedicaid
GA624397991DMedicaid
GAI40686Medicare UPIN