Basic Information
| Provider Information | |||||||||
| NPI: | 1568402162 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLACKER | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | MARSHALL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | EMMA I DARNELL GERIATRICS CENTER | ||||||||
| Address2: | 80 JESSE HILL JR DRIVE | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046167642 | ||||||||
| FaxNumber: | 4046162474 | ||||||||
| Practice Location | |||||||||
| Address1: | 1331 MOUNT ZION RD | ||||||||
| Address2: | |||||||||
| City: | MORROW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302602357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706293217 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 01/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 048148 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 048148 | 01 | GA | STATE LICENSE NUMBER | OTHER |