Provider Demographics
NPI:1790743300
Name:KNAUTZ, MARK ALLAN (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLAN
Last Name:KNAUTZ
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
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Mailing Address - Street 1:111 MARBLE MILL RD NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1047
Mailing Address - Country:US
Mailing Address - Phone:770-422-1013
Mailing Address - Fax:770-514-5996
Practice Address - Street 1:5041 DALLAS HWY
Practice Address - Street 2:SUITE D
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-6458
Practice Address - Country:US
Practice Address - Phone:770-427-5467
Practice Address - Fax:770-427-6340
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-12-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA041328207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA070008625OtherMEDICARE RAILROAD
GA52635067OtherBCBS
07BBCQCMedicare PIN
GA070008625OtherMEDICARE RAILROAD
GA07BBCQCMedicare ID - Type Unspecified