Provider Demographics
NPI:1427082494
Name:WHATLEY, LEWIS ROSS III (MD)
Entity type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:ROSS
Last Name:WHATLEY
Suffix:III
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 1:80 CARTER RD SW
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-7446
Mailing Address - Country:US
Mailing Address - Phone:770-386-5295
Mailing Address - Fax:
Practice Address - Street 1:424 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2644
Practice Address - Country:US
Practice Address - Phone:770-748-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0224902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00089064DMedicaid
GA30BDHLHMedicare ID - Type Unspecified
GA00089064DMedicaid