Provider Demographics
NPI:1730233859
Name:LASSITER, NOLAN MADDOX SR (MD)
Entity type:Individual
Prefix:DR
First Name:NOLAN
Middle Name:MADDOX
Last Name:LASSITER
Suffix:SR
Gender:M
Credentials:MD
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Mailing Address - Street 1:2176 OAK RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2374
Mailing Address - Country:US
Mailing Address - Phone:770-985-2900
Mailing Address - Fax:770-985-4572
Practice Address - Street 1:2176 OAK RD SW
Practice Address - Street 2:SUITE B
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078
Practice Address - Country:US
Practice Address - Phone:770-985-2900
Practice Address - Fax:770-985-4572
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA010220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D30020Medicare UPIN
GA110220130AMedicare ID - Type Unspecified