Provider Demographics
NPI:1518907625
Name:SKANDALAKIS, LEE JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:JOHN
Last Name:SKANDALAKIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3193 HOWELL MILL RD NW STE 125
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2100
Mailing Address - Country:US
Mailing Address - Phone:770-696-3586
Mailing Address - Fax:877-795-8175
Practice Address - Street 1:3193 HOWELL MILL RD NW STE 125
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2100
Practice Address - Country:US
Practice Address - Phone:770-696-3586
Practice Address - Fax:877-795-8175
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA27443208600000X
GA027443208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00307117BMedicaid
GA00307117BMedicaid
GA02BDCNOMedicare ID - Type Unspecified