Provider Demographics
NPI:1376612408
Name:MANSFIELD, DONALD LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:LEE
Last Name:MANSFIELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 MONTREAL RD
Mailing Address - Street 2:SUITE 316
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6929
Mailing Address - Country:US
Mailing Address - Phone:770-938-3813
Mailing Address - Fax:770-938-5371
Practice Address - Street 1:1462 MONTREAL RD
Practice Address - Street 2:SUITE 316
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6929
Practice Address - Country:US
Practice Address - Phone:770-938-3813
Practice Address - Fax:770-938-5371
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12349174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0057228AMedicaid
GAD30141Medicare UPIN