Provider Demographics
NPI:1740570183
Name:NATHANIEL, KALVIN LADELLE
Entity Type:Individual
Prefix:DR
First Name:KALVIN
Middle Name:LADELLE
Last Name:NATHANIEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 NEW NORTHSIDE DR
Mailing Address - Street 2:320
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5831
Mailing Address - Country:US
Mailing Address - Phone:770-874-5400
Mailing Address - Fax:
Practice Address - Street 1:5665 NEW NORTHSIDE DR
Practice Address - Street 2:320
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5831
Practice Address - Country:US
Practice Address - Phone:770-874-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72290207P00000X
LADO.000336207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine