Provider Demographics
NPI:1932263266
Name:LATHAN, SAMUEL ROBERT (MD, FACP, FACCP)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ROBERT
Last Name:LATHAN
Suffix:
Gender:M
Credentials:MD, FACP, FACCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 DOWNWOOD CIRCLE
Mailing Address - Street 2:SUITE 550
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327
Mailing Address - Country:US
Mailing Address - Phone:404-351-0205
Mailing Address - Fax:404-350-9823
Practice Address - Street 1:3200 DOWNWOOD CIR NW
Practice Address - Street 2:550
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1610
Practice Address - Country:US
Practice Address - Phone:404-351-0205
Practice Address - Fax:404-350-9823
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012337207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA012337OtherSTATE LICENSE NUMBER
D70531Medicare UPIN
GAD70531Medicare UPIN