MEDICARE: JOHN F MYNATT JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	041469	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	52701109002	OTHER	GA	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629037528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN F MYNATT JR. MD

Provider Business Mailing Address
First Line	:	5040 BILL GARDNER PKWY
Second Line	:	SUITE 100
City	:	LOCUST GROVE
State	:	GA
Zip	:	30248-3645
Country	:	US
Telephone Number	:	678-583-5437
Fax Number	:	678-583-5484

Provider Business Practice Location Address
First Line	:	5040 BILL GARDNER PKWY
Second Line	:	SUITE 100
City	:	LOCUST GROVE
State	:	GA
Zip	:	30248-3645
Country	:	US
Telephone Number	:	678-583-5437
Fax Number	:	678-583-5484

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2006
Last Update Date	:	06/23/2008

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