Provider Demographics
NPI:1063474013
Name:TATE, CANDICE (MD)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:TATE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:400 GALLERIA PKWY SE
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5980
Mailing Address - Country:US
Mailing Address - Phone:770-644-9212
Mailing Address - Fax:770-644-9213
Practice Address - Street 1:400 GALLERIA PKWY SE
Practice Address - Street 2:SUITE 1500
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5980
Practice Address - Country:US
Practice Address - Phone:770-644-9212
Practice Address - Fax:770-644-9213
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361095932084P0800X
GA0599672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK14005Medicare ID - Type Unspecified
I23857Medicare UPIN
IL207982Medicare ID - Type Unspecified