Provider Demographics
NPI:1245239094
Name:YANTA, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:YANTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3400 OLD MILTON PKWY # C
Mailing Address - Street 2:STE 365
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-3707
Mailing Address - Country:US
Mailing Address - Phone:404-446-2400
Mailing Address - Fax:404-446-2409
Practice Address - Street 1:3400 OLD MILTON PKWY # C
Practice Address - Street 2:STE 365
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-3707
Practice Address - Country:US
Practice Address - Phone:404-446-2400
Practice Address - Fax:404-446-2409
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA043827174400000X
GA43827207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3416408OtherAETNA
GA000749229HMedicaid
GA00749229HMedicaid
GA000749229WMedicaid
GA10034908Medicaid
GA296145Medicaid
GA3416408OtherAETNA
GA10034908Medicaid