Provider Demographics
NPI:1245298082
Name:MORDEL, NATHAN (MD)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:
Last Name:MORDEL
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 1:2500 HOSPITAL BLVD STE 340
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4977
Mailing Address - Country:US
Mailing Address - Phone:470-956-4590
Mailing Address - Fax:678-393-1969
Practice Address - Street 1:2500 HOSPITAL BLVD STE 340
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4977
Practice Address - Country:US
Practice Address - Phone:470-956-4590
Practice Address - Fax:678-393-1969
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045895207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA16BBBSPOtherMEDICARE ID/105 COLLIER ROAD SUITE 1010
GADA6300OtherMEDICARE RAILROAD PIN
GA00800148AMedicaid
GA45895OtherGA. MED. LICENSE
G71156Medicare UPIN
GA45895OtherGA. MED. LICENSE
GA16BDSKZMedicare ID - Type Unspecified1806 LEE AVE. TIFTON, GA