Provider Demographics
NPI:1184728255
Name:MULLIGAN, OLIVIA F (MD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:F
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:M
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2121 FOUNTAIN DRIVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2900
Mailing Address - Country:US
Mailing Address - Phone:770-979-4236
Mailing Address - Fax:770-979-4401
Practice Address - Street 1:2121 FOUNTAIN DRIVE
Practice Address - Street 2:SUITE F
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2900
Practice Address - Country:US
Practice Address - Phone:770-979-4236
Practice Address - Fax:770-979-4401
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19973207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00160619CMedicaid
GA00160619CMedicaid