=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770786584
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA L VARGAS VIVES MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2007
-----------------------------------------------------
Last Update Date | 10/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 285 BOULEVARD NE NEUROLOGY
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30312-4205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-653-0039
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3668 CANYON RIDGE CT NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30319-4823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-400-2269
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 071580
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------