Provider Demographics
NPI:1679574198
Name:NATHANSON, AVERY H (MD)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:H
Last Name:NATHANSON
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 1:2665 N DECATUR RD
Mailing Address - Street 2:STE 230
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6149
Mailing Address - Country:US
Mailing Address - Phone:404-499-0533
Mailing Address - Fax:404-499-0531
Practice Address - Street 1:2665 N DECATUR RD
Practice Address - Street 2:STE 230
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6149
Practice Address - Country:US
Practice Address - Phone:404-499-0533
Practice Address - Fax:404-499-0531
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054815207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA185405668AMedicaid
GA29BDCKZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
GA185405668AMedicaid