Provider Demographics
NPI:1235111832
Name:ATALA, ANTHONY JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOHN
Last Name:ATALA
Suffix:
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 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-0238
Mailing Address - Fax:
Practice Address - Street 1:140 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1522
Practice Address - Country:US
Practice Address - Phone:336-716-4131
Practice Address - Fax:336-713-0328
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400099208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891359JMedicaid
WV1810835000Medicaid
1359JOtherBCBS
VA10078199Medicaid
7644683OtherAETNA
804009OtherPARTNERS
D2424OtherMEDCOST
804009OtherPARTNERS
NC891359JMedicaid