Healthcare Provider Details

I. General information

NPI: 1518923879
Provider Name (Legal Business Name): MANDANA REZAEI-AMIRI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1686 ROSWELL RD
MARIETTA GA
30062-3621
US

IV. Provider business mailing address

1686 ROSWELL RD
MARIETTA GA
30062-3621
US

V. Phone/Fax

Practice location:
  • Phone: 770-933-9333
  • Fax: 770-579-9331
Mailing address:
  • Phone: 770-933-9333
  • Fax: 770-579-9331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number046904
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: