Provider Demographics
NPI:1194828541
Name:MIMS, ADRIENNE D (MD MPH)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:D
Last Name:MIMS
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:770-629-3217
Mailing Address - Fax:
Practice Address - Street 1:1331 MOUNT ZION RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2357
Practice Address - Country:US
Practice Address - Phone:770-629-3217
Practice Address - Fax:770-968-4358
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA033152207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E32587Medicare UPIN
08BDCCHMedicare ID - Type Unspecified