Provider Demographics
NPI:1699215541
Name:MARY M FELDMAN MD LLC
Entity Type:Organization
Organization Name:MARY M FELDMAN MD LLC
Other - Org Name:CARROLLTON DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FELDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-231-5544
Mailing Address - Street 1:100 PROFESSIONAL PL
Mailing Address - Street 2:STE 110
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3874
Mailing Address - Country:US
Mailing Address - Phone:770-834-0818
Mailing Address - Fax:770-834-5098
Practice Address - Street 1:100 PROFESSIONAL PL
Practice Address - Street 2:STE 110
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3874
Practice Address - Country:US
Practice Address - Phone:770-834-0818
Practice Address - Fax:770-834-5098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-26
Last Update Date:2017-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA69043261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH65098Medicare UPIN