=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518932185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MERNA MICHELLE VERA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2006
-----------------------------------------------------
Last Update Date | 02/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 PERMIAN WAY SUITE A
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-3252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-771-5235
-----------------------------------------------------
Fax | 770-771-5236
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1615
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-6409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-771-5235
-----------------------------------------------------
Fax | 770-771-5236
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 052136
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------