Basic Information
| Provider Information | |||||||||
| NPI: | 1003818741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONATI | ||||||||
| FirstName: | NORMAN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 370 | ||||||||
| Address2: | |||||||||
| City: | FORTSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 318080370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7064943008 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N MACON ST | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312106563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782006970 | ||||||||
| FaxNumber: | 4782165976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 041777 | GA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 300034635A | 05 | GA | MEDICAID |