Provider Demographics
NPI:1023694890
Name:HAVERSTICK, NATHAN GRANT (DO)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:GRANT
Last Name:HAVERSTICK
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Gender:M
Credentials:DO
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Mailing Address - Street 1:1230 BAXTER STREET
Mailing Address - Street 2:ST. MARY'S HEALTH CARE SYSTEM, INC. GRADUATE MEDICAL ED
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3712
Mailing Address - Country:US
Mailing Address - Phone:706-389-3860
Mailing Address - Fax:706-389-3861
Practice Address - Street 1:COMMUNITY INTERNAL MEDICINE OF ATHENS
Practice Address - Street 2:1500 OGLETHORPE AVE SUITE 200D
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-389-3875
Practice Address - Fax:706-389-3876
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2022-08-05
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Provider Licenses
StateLicense IDTaxonomies
390200000X
GA13703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA13703OtherGEORGIA COMPOSITE MEDICAL BOARD