=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184069510
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARVIN MANSUKHBHAI VAISHNANI M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2013
-----------------------------------------------------
Last Update Date | 04/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 745 POPLAR RD
-----------------------------------------------------
City | NEWNAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30265-1618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-400-2353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 REDMOND RD NW
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30165-1415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-291-0291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 75939
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 75939
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------