Healthcare Provider Details

I. General information

NPI: 1245239094
Provider Name (Legal Business Name): MARK J. YANTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 OLD MILTON PKWY # C STE 365
ALPHARETTA GA
30005-3707
US

IV. Provider business mailing address

3400 OLD MILTON PKWY # C STE 365
ALPHARETTA GA
30005-3707
US

V. Phone/Fax

Practice location:
  • Phone: 404-446-2400
  • Fax: 404-446-2409
Mailing address:
  • Phone: 404-446-2400
  • Fax: 404-446-2409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number043827
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number43827
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: