Healthcare Provider Details

I. General information

NPI: 1124188768
Provider Name (Legal Business Name): MR. PRAMOD MATHUR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1159 MONTE DR
MARIETTA GA
30062-2896
US

IV. Provider business mailing address

1159 MONTE DR
MARIETTA GA
30062-2896
US

V. Phone/Fax

Practice location:
  • Phone: 770-321-6142
  • Fax: 770-509-5364
Mailing address:
  • Phone: 770-321-6142
  • Fax: 770-509-5364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number033-R-0094
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: