Healthcare Provider Details

I. General information

NPI: 1598739559
Provider Name (Legal Business Name): MARK J. MITTENTHAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5669 PEACHTREE DUNWOODY RD SUITE 100
ATLANTA GA
30342-1786
US

IV. Provider business mailing address

1838 AMERICAN WAY
LAWRENCEVILLE GA
30043-6611
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-0404
  • Fax: 404-847-0423
Mailing address:
  • Phone: 770-995-7622
  • Fax: 770-995-7854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number017864
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: