Provider Demographics
NPI:1013198142
Name:ALTADONNA, LORIEN T (MD)
Entity Type:Individual
Prefix:
First Name:LORIEN
Middle Name:T
Last Name:ALTADONNA
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 1:705 DIXIE STREET
Mailing Address - Street 2:WEST GEORGIA PATHOLOGY, LLC AT TANNER MEDICAL CENTER
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3818
Mailing Address - Country:US
Mailing Address - Phone:770-836-9672
Mailing Address - Fax:770-838-8827
Practice Address - Street 1:705 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3818
Practice Address - Country:US
Practice Address - Phone:770-836-9672
Practice Address - Fax:770-838-8827
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMD.28629207ZP0102X, 207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2021221829OtherMEDICARE
GA218387735AMedicaid