Provider Demographics
NPI:1467430363
Name:CARLOCK, KELLER S (MD)
Entity Type:Individual
Prefix:
First Name:KELLER
Middle Name:S
Last Name:CARLOCK
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 1:1984 PEACHTREE RD NW
Mailing Address - Street 2:SUITE 505
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-5219
Mailing Address - Country:US
Mailing Address - Phone:404-352-1409
Mailing Address - Fax:404-352-8176
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-605-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA422022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000445794BMedicaid
GA30BDKCJMedicare PIN
GA000445794BMedicaid