Provider Demographics
NPI:1306931548
Name:DRAYTON, DEKISHA PENDERGRASS (MD)
Entity type:Individual
Prefix:
First Name:DEKISHA
Middle Name:PENDERGRASS
Last Name:DRAYTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEKISHA
Other - Middle Name:M
Other - Last Name:PENDERGRASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6279 VININGS VINTAGE DR
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-7202
Mailing Address - Country:US
Mailing Address - Phone:404-394-6155
Mailing Address - Fax:
Practice Address - Street 1:3885 PRINCETON LAKES WAY
Practice Address - Street 2:SUITE 302
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331
Practice Address - Country:US
Practice Address - Phone:404-629-1880
Practice Address - Fax:404-629-1935
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053016208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA118918947BMedicaid
GA118918947BMedicaid