Provider Demographics
NPI:1356533145
Name:NINAN, MARY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:JOHN
Last Name:NINAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:678-566-6995
Mailing Address - Fax:678-566-0346
Practice Address - Street 1:6300 HOSPITAL PKWY STE 300
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1982
Practice Address - Country:US
Practice Address - Phone:770-623-8965
Practice Address - Fax:770-623-4018
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA058551207RH0003X
TX43128207RH0003X
TXN7955207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG10127AOtherMEDICARE PTAN
GA003158193CMedicaid
GA003158193DMedicaid