Basic Information
| Provider Information | |||||||||
| NPI: | 1205839891 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GHIATHI | ||||||||
| FirstName: | ABDOLLATIF | ||||||||
| MiddleName: | SALEH | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312013490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783012362 | ||||||||
| FaxNumber: | 4783012272 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 HARTFORD RD W STE 1 | ||||||||
| Address2: | |||||||||
| City: | FORT GAINES | ||||||||
| State: | GA | ||||||||
| PostalCode: | 398514331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292102100 | ||||||||
| FaxNumber: | 4783015812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 040908 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00680688F | 05 | GA | MEDICAID |