Healthcare Provider Details

I. General information

NPI: 1457493918
Provider Name (Legal Business Name): MINDY GENTRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3747 ROSWELL RD
MARIETTA GA
30062-6234
US

IV. Provider business mailing address

3747 ROSWELL RD STE 213
MARIETTA GA
30062-6227
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-6893
  • Fax: 770-528-9938
Mailing address:
  • Phone: 770-321-3490
  • Fax: 770-321-3489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number052938
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: