Provider Demographics
NPI:1669462610
Name:MOFID, MITRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:MOFID
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 1:3843 CHATTAHOOCHEE SUMMIT DR SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3253
Mailing Address - Country:US
Mailing Address - Phone:714-328-0331
Mailing Address - Fax:
Practice Address - Street 1:2550 WINDY HILL ROAD SE
Practice Address - Street 2:SUITE 103
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8607
Practice Address - Country:US
Practice Address - Phone:770-952-0050
Practice Address - Fax:770-381-6451
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051166207NS0135X, 207N00000X
CAA62702207NS0135X, 207N00000X
KY38362207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH30456Medicare UPIN
CAH30456Medicare UPIN
GA07BBSLRMedicare ID - Type UnspecifiedGA MPIN