Provider Demographics
NPI:1942291455
Name:KOLB, SUSAN ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:KOLB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 AVIGNON CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-1038
Mailing Address - Country:US
Mailing Address - Phone:770-399-0412
Mailing Address - Fax:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031272208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000379486CMedicaid
GA24BCBCMMedicare PIN
GAE95541Medicare UPIN