Provider Demographics
NPI:1609031657
Name:KIBUYAGA-TRAVIS, NAKATO B (MD)
Entity Type:Individual
Prefix:MS
First Name:NAKATO
Middle Name:B
Last Name:KIBUYAGA-TRAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT ROAD, NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1736
Mailing Address - Country:US
Mailing Address - Phone:404-364-7070
Mailing Address - Fax:678-336-7099
Practice Address - Street 1:6043 PRESTLEY MILL RD STE B
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2280
Practice Address - Country:US
Practice Address - Phone:770-947-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003467207Q00000X
GA066960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine