Healthcare Provider Details

I. General information

NPI: 1013916212
Provider Name (Legal Business Name): VICKI D KNIGHT-MATHIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 MARIETTA HWY SUITE 142
CANTON GA
30114-8212
US

IV. Provider business mailing address

2920 MARIETTA HWY SUITE 142
CANTON GA
30114-8212
US

V. Phone/Fax

Practice location:
  • Phone: 770-704-0057
  • Fax: 770-704-0223
Mailing address:
  • Phone: 770-704-0057
  • Fax: 770-704-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number47337
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: