Healthcare Provider Details

I. General information

NPI: 1548209224
Provider Name (Legal Business Name): MARK W HUTSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 CENTURY BLVD NE SUITE 150
ATLANTA GA
30345-3319
US

IV. Provider business mailing address

1875 CENTURY BLVD NE SUITE 150
ATLANTA GA
30345-3319
US

V. Phone/Fax

Practice location:
  • Phone: 404-633-4595
  • Fax: 404-633-6637
Mailing address:
  • Phone: 404-633-4595
  • Fax: 404-633-6637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number035908
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: