Healthcare Provider Details

I. General information

NPI: 1114629755
Provider Name (Legal Business Name): JONATHAN DOUGLAS HEAVEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 EXECUTIVE PARK DR NE STE 200
ATLANTA GA
30329-2206
US

IV. Provider business mailing address

12 EXECUTIVE PARK DR NE STE 200
ATLANTA GA
30329-2206
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-6934
  • Fax:
Mailing address:
  • Phone: 404-712-6934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: