Healthcare Provider Details

I. General information

NPI: 1316904147
Provider Name (Legal Business Name): JARED SAMUEL FRIEDMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MARBLE MILL RD NW
MARIETTA GA
30060-1047
US

IV. Provider business mailing address

111 MARBLE MILL RD NW
MARIETTA GA
30060-1047
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-1013
  • Fax: 770-514-5996
Mailing address:
  • Phone: 770-422-1013
  • Fax: 770-514-5996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD52722
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number052722
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: