Healthcare Provider Details

I. General information

NPI: 1558887018
Provider Name (Legal Business Name): MIGUEL E. STUBBS, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 AUSTELL RD STE 1
AUSTELL GA
30106-2007
US

IV. Provider business mailing address

6724 CHURCH ST STE 3
RIVERDALE GA
30274-4711
US

V. Phone/Fax

Practice location:
  • Phone: 404-803-5146
  • Fax: 770-991-5012
Mailing address:
  • Phone: 770-991-6186
  • Fax: 770-991-5012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MIGUEL E STUBBS
Title or Position: CEO
Credential: MD
Phone: 404-803-5246