Healthcare Provider Details

I. General information

NPI: 1407833015
Provider Name (Legal Business Name): MARIELI A COLON D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 FOREST PKWY STE 101
FOREST PARK GA
30297
US

IV. Provider business mailing address

425 FOREST PKWY SUITE 101
FOREST PARK GA
30297-2185
US

V. Phone/Fax

Practice location:
  • Phone: 404-363-9944
  • Fax: 404-363-9951
Mailing address:
  • Phone: 404-363-9944
  • Fax: 404-363-9951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number000996
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: