Healthcare Provider Details

I. General information

NPI: 1013870179
Provider Name (Legal Business Name): ROBERTO MINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 CLIFTON ST NE STE 4400
ATLANTA GA
30317
US

IV. Provider business mailing address

136 CLIFTON ST NE STE 4400
ATLANTA GA
30317
US

V. Phone/Fax

Practice location:
  • Phone: 943-294-0885
  • Fax:
Mailing address:
  • Phone: 943-294-0885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number110612
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: