Provider Demographics
NPI:1043228364
Name:ROLLINS III MD, LUTHER C III (MD)
Entity Type:Individual
Prefix:
First Name:LUTHER
Middle Name:C
Last Name:ROLLINS III MD
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 HAMMOND DRIVE, NE
Mailing Address - Street 2:BLDG D-4190
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328
Mailing Address - Country:US
Mailing Address - Phone:770-558-8501
Mailing Address - Fax:770-558-8512
Practice Address - Street 1:1140 HAMMOND DRIVE, NE
Practice Address - Street 2:BLDG D-4190
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:404-351-1745
Practice Address - Fax:404-351-7121
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023101174400000X, 207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No174400000XOther Service ProvidersSpecialist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA023101OtherLICENSE
GALICENSEOther023101
GA000281652AMedicaid
GA05BDKLHMedicare ID - Type UnspecifiedMEDICARE GROUP #
D30644Medicare UPIN
GA000281652AMedicaid