Provider Demographics
NPI:1487865952
Name:ATHENS DIABETES AND ENDOCRINOLOGY
Entity Type:Organization
Organization Name:ATHENS DIABETES AND ENDOCRINOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:FRANDSEN
Authorized Official - Last Name:VANDYCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-549-4155
Mailing Address - Street 1:3320 OLD JEFFERSON RD STE 600
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-1463
Mailing Address - Country:US
Mailing Address - Phone:706-549-4155
Mailing Address - Fax:706-546-0036
Practice Address - Street 1:3320 OLD JEFFERSON RD STE 600
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-1463
Practice Address - Country:US
Practice Address - Phone:706-549-4155
Practice Address - Fax:706-546-0036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA27679207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0384997BMedicaid
GA0384997BMedicaid
11BDBKLMedicare ID - Type Unspecified