Basic Information
Provider Information | |||||||||
NPI: | 1730183377 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NATH | ||||||||
FirstName: | VIJAY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 55 WHITCHER ST NE | ||||||||
Address2: | STE 460 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300601171 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704277389 | ||||||||
FaxNumber: | 7704272845 | ||||||||
Practice Location | |||||||||
Address1: | 55 WHITCHER ST NE | ||||||||
Address2: | STE 460 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300601171 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704277389 | ||||||||
FaxNumber: | 7704272845 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2005 | ||||||||
LastUpdateDate: | 08/01/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 055690 | MO | N |   | Other Service Providers | Specialist |   | 207RN0300X | GA055690 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 437284962K | 05 | GA |   | MEDICAID | 437284962V | 05 | GA |   | MEDICAID | 437284962G | 05 | GA |   | MEDICAID | 437284962F | 05 | GA |   | MEDICAID | 437284962H | 05 | GA |   | MEDICAID | 437284962U | 05 | GA |   | MEDICAID | 437284962J | 05 | GA |   | MEDICAID | 437284962B | 05 | GA |   | MEDICAID | 437284962C | 05 | GA |   | MEDICAID | 437284962P | 05 | GA |   | MEDICAID | 437284962R | 05 | GA |   | MEDICAID | 437284962A | 05 | GA |   | MEDICAID | 437284962D | 05 | GA |   | MEDICAID | 437284962E | 05 | GA |   | MEDICAID | 437284962Q | 05 | GA |   | MEDICAID | 437284962S | 05 | GA |   | MEDICAID | 437284962L | 05 | GA |   | MEDICAID | 437284962N | 05 | GA |   | MEDICAID | 437284962O | 05 | GA |   | MEDICAID | 437284962T | 05 | GA |   | MEDICAID |