Provider Demographics
NPI:1558459479
Name:MOSLEY, MARY JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JACKSON
Last Name:MOSLEY
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:PO BOX 403631
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-3631
Mailing Address - Country:US
Mailing Address - Phone:770-740-0895
Mailing Address - Fax:770-740-0896
Practice Address - Street 1:2701 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5918
Practice Address - Country:US
Practice Address - Phone:404-501-5422
Practice Address - Fax:404-501-1771
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45252207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine