Provider Demographics
NPI:1841297793
Name:LANCLOS, KEVIN D (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:LANCLOS
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 1:551 N CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:SOCIAL CIRCLE
Mailing Address - State:GA
Mailing Address - Zip Code:30025-2887
Mailing Address - Country:US
Mailing Address - Phone:770-787-6900
Mailing Address - Fax:770-787-6962
Practice Address - Street 1:551 N CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:SOCIAL CIRCLE
Practice Address - State:GA
Practice Address - Zip Code:30025-2887
Practice Address - Country:US
Practice Address - Phone:770-787-6900
Practice Address - Fax:770-787-6962
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA47109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11BDQLJMedicare ID - Type Unspecified
GA00833027AMedicaid
GAH00741Medicare UPIN