Provider Demographics
NPI:1366419129
Name:CLOSE, LANNY GARTH (MD)
Entity type:Individual
Prefix:
First Name:LANNY
Middle Name:GARTH
Last Name:CLOSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5670 PEACHTREE DUNWOODY RD STE 1280
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4792
Mailing Address - Country:US
Mailing Address - Phone:404-257-1589
Mailing Address - Fax:404-303-1950
Practice Address - Street 1:5670 PEACHTREE DUNWOODY RD STE 1280
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-257-1589
Practice Address - Fax:404-303-1950
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198569207Y00000X
GA079175207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB21906Medicare UPIN
NY19J55XVTP1Medicare PIN