Healthcare Provider Details

I. General information

NPI: 1336258193
Provider Name (Legal Business Name): IAN T. NATHANSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S ORANGE AVE SUITE 100
ORLANDO FL
32806-2944
US

IV. Provider business mailing address

NEMOURS CHILDREN&APOS S CLINIC PO BOX 409992
ATLANTA GA
30384-0001
US

V. Phone/Fax

Practice location:
  • Phone: 407-650-7000
  • Fax: 407-650-7124
Mailing address:
  • Phone: 904-390-3610
  • Fax: 904-288-5890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberME55343
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: