Provider Demographics
NPI:1508206319
Name:DANIEL, MITHUN SAM (D O)
Entity type:Individual
Prefix:
First Name:MITHUN
Middle Name:SAM
Last Name:DANIEL
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:MITHUN
Other - Middle Name:
Other - Last Name:DANIEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:960 JOHNSON FY RD NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1631
Mailing Address - Country:US
Mailing Address - Phone:404-255-7325
Mailing Address - Fax:404-255-3055
Practice Address - Street 1:960 JOHNSON FY RD NE
Practice Address - Street 2:SUITE 300
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1631
Practice Address - Country:US
Practice Address - Phone:404-255-7325
Practice Address - Fax:404-255-3055
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA075104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I086980Medicare UPIN