Provider Demographics
NPI:1558319467
Name:MOSUNJAC, MARIO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:MOSUNJAC
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 1:80 JESSE HILL JR. DR.
Mailing Address - Street 2:ROOM CG-39
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303
Mailing Address - Country:US
Mailing Address - Phone:404-616-7429
Mailing Address - Fax:404-616-9084
Practice Address - Street 1:80 JESSE HILL JR. DR.
Practice Address - Street 2:ROOM CG-39
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303
Practice Address - Country:US
Practice Address - Phone:404-616-7429
Practice Address - Fax:404-616-9084
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046625207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH00693Medicare UPIN