Healthcare Provider Details

I. General information

NPI: 1790743300
Provider Name (Legal Business Name): MARK ALLAN KNAUTZ MEDICAL DOCTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5041 DALLAS HWY SUITE D
POWDER SPRINGS GA
30127-6458
US

IV. Provider business mailing address

111 MARBLE MILL RD NW
MARIETTA GA
30060-1047
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-5467
  • Fax: 770-427-6340
Mailing address:
  • Phone: 770-422-1013
  • Fax: 770-514-5996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number041328
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: