Provider Demographics
NPI:1366522690
Name:KNOWLTON, GREGORY B (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:B
Last Name:KNOWLTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5671 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-5000
Mailing Address - Country:US
Mailing Address - Phone:404-855-7030
Mailing Address - Fax:678-843-6619
Practice Address - Street 1:5671 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 500
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5000
Practice Address - Country:US
Practice Address - Phone:404-855-7030
Practice Address - Fax:678-843-6619
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018037207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00143943AMedicaid
GA00143943AMedicaid
GA102I391459Medicare PIN