Healthcare Provider Details

I. General information

NPI: 1518962414
Provider Name (Legal Business Name): OFELIA S MANDOCK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COUNTY SERVICES PKWY SW
MARIETTA GA
30008-4010
US

IV. Provider business mailing address

1650 COUNTY SERVICES PKWY SW
MARIETTA GA
30008-4010
US

V. Phone/Fax

Practice location:
  • Phone: 770-514-2361
  • Fax: 770-514-2811
Mailing address:
  • Phone: 770-514-2361
  • Fax: 770-514-2811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number37447
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: