Provider Demographics
NPI:1104190644
Name:JEFFREY H. FLATOW, M.D., LLC
Entity Type:Organization
Organization Name:JEFFREY H. FLATOW, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:H
Authorized Official - Last Name:FLATOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-985-9030
Mailing Address - Street 1:5435 SUGARLOAF PKWY
Mailing Address - Street 2:SUITE 1104
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7831
Mailing Address - Country:US
Mailing Address - Phone:678-985-9030
Mailing Address - Fax:678-985-9485
Practice Address - Street 1:5435 SUGARLOAF PKWY
Practice Address - Street 2:SUITE 1104
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7831
Practice Address - Country:US
Practice Address - Phone:678-985-9030
Practice Address - Fax:678-985-9485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028543261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00384777BMedicaid
GA26BDHTBMedicare PIN