Provider Demographics
NPI:1013916212
Name:KNIGHT-MATHIS, VICKI D (MD)
Entity Type:Individual
Prefix:DR
First Name:VICKI
Middle Name:D
Last Name:KNIGHT-MATHIS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2920 MARIETTA HWY
Mailing Address - Street 2:SUITE 142
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-8212
Mailing Address - Country:US
Mailing Address - Phone:770-704-0057
Mailing Address - Fax:770-704-0223
Practice Address - Street 1:2920 MARIETTA HWY
Practice Address - Street 2:SUITE 142
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-8212
Practice Address - Country:US
Practice Address - Phone:770-704-0057
Practice Address - Fax:770-704-0223
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA47337208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00824788BMedicaid