Healthcare Provider Details

I. General information

NPI: 1972828671
Provider Name (Legal Business Name): NATHALIE MANTILLA FARFAN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NATHALIE MANTILLA

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 WALTON WAY STE 6500
AUGUSTA GA
30901-5111
US

IV. Provider business mailing address

1130 S MICHIGAN AVE APT 3104
CHICAGO IL
60605-2322
US

V. Phone/Fax

Practice location:
  • Phone: 706-722-2118
  • Fax:
Mailing address:
  • Phone: 312-927-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036140788
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number036140788
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number101399
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: