Healthcare Provider Details

I. General information

NPI: 1629076799
Provider Name (Legal Business Name): GONZALO MANTILLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 FRANKLIN GTWY SE
MARIETTA GA
30067-7803
US

IV. Provider business mailing address

777 FRANKLIN GTWY SE
MARIETTA GA
30067-7803
US

V. Phone/Fax

Practice location:
  • Phone: 770-732-6007
  • Fax:
Mailing address:
  • Phone: 770-732-6007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberME 22858
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: