Healthcare Provider Details

I. General information

NPI: 1477012243
Provider Name (Legal Business Name): MANUEL COUTINHO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MARBLE MILL RD NW
MARIETTA GA
30060-7959
US

IV. Provider business mailing address

121 MARBLE MILL RD NW
MARIETTA GA
30060-7959
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-8315
  • Fax: 770-590-9170
Mailing address:
  • Phone: 770-422-8315
  • Fax: 770-590-9170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number315941
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number102857
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: