Basic Information
| Provider Information | |||||||||
| NPI: | 1841511797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONATIEN | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 740015 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303740015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | 7738668014 | ||||||||
| Practice Location | |||||||||
| Address1: | 1825 ROCKBRIDGE RD STE 15B | ||||||||
| Address2: | |||||||||
| City: | STONE MOUNTAIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300873306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4704443134 | ||||||||
| FaxNumber: | 4702764370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2010 | ||||||||
| LastUpdateDate: | 05/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 88976 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14S65 | 01 | FL | FLORIDA BLUE | OTHER | 009371000 | 05 | FL | MEDICAID |