Provider Demographics
NPI:1407833015
Name:COLON, MARIELI A (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARIELI
Middle Name:A
Last Name:COLON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 FOREST PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-2185
Mailing Address - Country:US
Mailing Address - Phone:404-363-9944
Mailing Address - Fax:404-363-9951
Practice Address - Street 1:425 FOREST PKWY STE 101
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297
Practice Address - Country:US
Practice Address - Phone:404-363-9944
Practice Address - Fax:404-363-9951
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000996213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA510199753AMedicaid
GA510199753BMedicaid
V00157Medicare UPIN
48SCCPDMedicare ID - Type Unspecified