Provider Demographics
NPI:1386228997
Name:MADISON, LA'DARIUS C (MPH, RDN, LD)
Entity Type:Individual
Prefix:
First Name:LA'DARIUS
Middle Name:C
Last Name:MADISON
Suffix:
Gender:M
Credentials:MPH, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6614 OVERLOOK RDG
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-1394
Mailing Address - Country:US
Mailing Address - Phone:205-617-6276
Mailing Address - Fax:
Practice Address - Street 1:6614 OVERLOOK RDG
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-1394
Practice Address - Country:US
Practice Address - Phone:205-617-6276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD005090133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered