Healthcare Provider Details

I. General information

NPI: 1790786911
Provider Name (Legal Business Name): DREW MATTHEW LOCANDRO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 LACY ST NW NORTHWEST ENT AND ALLERGY CENTER
MARIETTA GA
30060
US

IV. Provider business mailing address

80 LACY ST NW NORTHWEST ENT AND ALLERGY CENTER
MARIETTA GA
30060
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-0368
  • Fax: 678-581-5969
Mailing address:
  • Phone: 770-427-0368
  • Fax: 678-581-5969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number31970
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: