Provider Demographics
NPI:1366473837
Name:MAYFIELD, JAN RENEE (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:RENEE
Last Name:MAYFIELD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 HOSIERY MILL RD
Mailing Address - Street 2:STE 124
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-1688
Mailing Address - Country:US
Mailing Address - Phone:678-986-2220
Mailing Address - Fax:
Practice Address - Street 1:1200 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2529
Practice Address - Country:US
Practice Address - Phone:706-278-2105
Practice Address - Fax:865-291-3228
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051355207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000967766BMedicaid
GAP00232715OtherRAILROAD MEDICARE
GA93BFBBHMedicare PIN