Provider Demographics
NPI:1902846850
Name:MAYVILLE, CHRISTINA L (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:L
Last Name:MAYVILLE
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 1:389 MULBERRY ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7914
Mailing Address - Country:US
Mailing Address - Phone:478-743-9123
Mailing Address - Fax:478-742-9809
Practice Address - Street 1:389 MULBERRY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7914
Practice Address - Country:US
Practice Address - Phone:478-743-9123
Practice Address - Fax:478-742-9809
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0434232084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG54527Medicare UPIN