Healthcare Provider Details

I. General information

NPI: 1487349577
Provider Name (Legal Business Name): JONATHAN WALTER KALENIK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 COLONIAL DR
COLUMBIA SC
29203-6930
US

IV. Provider business mailing address

665 DULUTH HWY STE 501
LAWRENCEVILLE GA
30046-8709
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-7399
  • Fax:
Mailing address:
  • Phone: 678-312-0400
  • Fax: 678-312-0423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number112922
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number89998
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: