Healthcare Provider Details

I. General information

NPI: 1477256048
Provider Name (Legal Business Name): MIRA ITANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 PERNOSHAL CT
DUNWOODY GA
30338-6405
US

IV. Provider business mailing address

2021 PERNOSHAL CT
DUNWOODY GA
30338-6405
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-6920
  • Fax: 404-778-6901
Mailing address:
  • Phone: 404-778-6920
  • Fax: 404-778-6901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15452
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: