Provider Demographics
NPI:1689670804
Name:NINO, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:NINO
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 1:6002 PROFESSIONAL PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5600
Mailing Address - Country:US
Mailing Address - Phone:770-949-4200
Mailing Address - Fax:770-949-5553
Practice Address - Street 1:6002 PROFESSIONAL PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5600
Practice Address - Country:US
Practice Address - Phone:770-949-4200
Practice Address - Fax:770-949-5553
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045901207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000799202AMedicaid
04BDBWLMedicare ID - Type Unspecified
GA000799202AMedicaid