Provider Demographics
NPI:1396767893
Name:FELDMAN, MARY M (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:FELDMAN
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 1:3707 RANDALL MILL RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2713
Mailing Address - Country:US
Mailing Address - Phone:504-231-5544
Mailing Address - Fax:
Practice Address - Street 1:100 PROFESSIONAL PL
Practice Address - Street 2:SUITE 110
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3874
Practice Address - Country:US
Practice Address - Phone:770-834-0818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003004218207N00000X, 207ZP0102X, 207ZD0900X
GA69403207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH65098Medicare UPIN
GAH65098Medicare UPIN