Healthcare Provider Details

I. General information

NPI: 1619944279
Provider Name (Legal Business Name): ATLANTA I.D. GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 PEACHTREE RD NE SUITE 640
ATLANTA GA
30309-1476
US

IV. Provider business mailing address

2001 PEACHTREE RD NE SUITE 640
ATLANTA GA
30309-1476
US

V. Phone/Fax

Practice location:
  • Phone: 404-355-3161
  • Fax: 404-355-1353
Mailing address:
  • Phone: 404-355-3161
  • Fax: 404-355-1353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number19066
License Number StateGA

VIII. Authorized Official

Name: DR. CARLOS E LOPEZ
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 404-355-3161