Healthcare Provider Details

I. General information

NPI: 1679921662
Provider Name (Legal Business Name): MAX PRAYA MAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 CHURCH ST NE STE 400
MARIETTA GA
30060-8957
US

IV. Provider business mailing address

PO BOX 3157
INDIANAPOLIS IN
46206-3157
US

V. Phone/Fax

Practice location:
  • Phone: 770-405-2976
  • Fax:
Mailing address:
  • Phone: 770-405-2976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number008270
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number008270
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: