Healthcare Provider Details

I. General information

NPI: 1396767893
Provider Name (Legal Business Name): MARY M FELDMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PROFESSIONAL PL SUITE 110
CARROLLTON GA
30117-3874
US

IV. Provider business mailing address

3707 RANDALL MILL RD NW
ATLANTA GA
30327-2713
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-0818
  • Fax:
Mailing address:
  • Phone: 504-231-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2003004218
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2003004218
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number2003004218
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number69403
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: