Healthcare Provider Details

I. General information

NPI: 1750670154
Provider Name (Legal Business Name): BETHANY MILLIRON CAVAZUTI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
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: 678-239-0420
  • Fax:
Mailing address:
  • Phone: 855-871-1526
  • Fax: 855-277-8543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number077982
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number077982
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: