Provider Demographics
NPI:1427040799
Name:NORTH ATLANTA DERMATOLOGY
Entity Type:Organization
Organization Name:NORTH ATLANTA DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-493-5252
Mailing Address - Street 1:3850 PLEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4807
Mailing Address - Country:US
Mailing Address - Phone:770-814-8222
Mailing Address - Fax:
Practice Address - Street 1:3850 PLEASANT HILL RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4807
Practice Address - Country:US
Practice Address - Phone:770-814-8222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2004000225207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300033599AMedicaid
GA300033599BMedicaid
GA55003258AMedicaid
GA11D1050070OtherCLIA ADDL LOCATION
GA11D0973833OtherCLIA #
GA11D0973833OtherCLIA #