Healthcare Provider Details

I. General information

NPI: 1881698546
Provider Name (Legal Business Name): MIRIAM P GWATHNEY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 MAIN ST
FOREST PARK GA
30297-1482
US

IV. Provider business mailing address

1057 MAIN ST
FOREST PARK GA
30297-1482
US

V. Phone/Fax

Practice location:
  • Phone: 404-301-4555
  • Fax: 404-301-4482
Mailing address:
  • Phone: 404-301-4555
  • Fax: 404-301-4482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS8157
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number063343
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: