Provider Demographics
NPI:1225091341
Name:EAST, MARY JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JEAN
Last Name:EAST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:JEAN
Other - Last Name:EAST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:539 HARDEE ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-4711
Mailing Address - Country:US
Mailing Address - Phone:770-505-0531
Mailing Address - Fax:770-485-0570
Practice Address - Street 1:539 HARDEE ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-4711
Practice Address - Country:US
Practice Address - Phone:770-505-0531
Practice Address - Fax:770-485-0570
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN032537363LF0000X
GA063187207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000430515AMedicaid
GA085000588GMedicaid
GA000430515AMedicaid
GA085000588GMedicaid