Provider Demographics
NPI:1568521052
Name:OVERSTREET, LATHAN WYATT (MD)
Entity Type:Individual
Prefix:
First Name:LATHAN
Middle Name:WYATT
Last Name:OVERSTREET
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:PO BOX 42827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-0827
Mailing Address - Country:US
Mailing Address - Phone:404-699-7096
Mailing Address - Fax:404-699-9933
Practice Address - Street 1:3355 CASCADE RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-3618
Practice Address - Country:US
Practice Address - Phone:404-699-7096
Practice Address - Fax:404-699-9933
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036659174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00646665CMedicaid
GA00646665CMedicaid
GAF97830Medicare UPIN