Healthcare Provider Details

I. General information

NPI: 1871673749
Provider Name (Legal Business Name): GREGORY LOY MAULDIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 TREE LANE ROAD SUITE 200
SNELLVILLE GA
30078
US

IV. Provider business mailing address

1800 TREE LANE ROAD SUITE 200
SNELLVILLE GA
30078
US

V. Phone/Fax

Practice location:
  • Phone: 770-979-0367
  • Fax: 770-979-1830
Mailing address:
  • Phone: 770-979-0367
  • Fax: 770-979-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number36567
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036567
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: