Provider Demographics
NPI:1336636679
Name:MAHMUTOVIC, MINELA (CST/CSFA)
Entity Type:Individual
Prefix:
First Name:MINELA
Middle Name:
Last Name:MAHMUTOVIC
Suffix:
Gender:F
Credentials:CST/CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 NEW HOPE RD
Mailing Address - Street 2:SUITE 11-526
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-6576
Mailing Address - Country:US
Mailing Address - Phone:404-921-4973
Mailing Address - Fax:
Practice Address - Street 1:930 NEW HOPE RD
Practice Address - Street 2:SUITE 11-526
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045
Practice Address - Country:US
Practice Address - Phone:404-921-4973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant