Provider Demographics
NPI:1811955826
Name:ANI, MARYGRACE REYES (MD)
Entity type:Individual
Prefix:
First Name:MARYGRACE
Middle Name:REYES
Last Name:ANI
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 1:3000 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5683
Mailing Address - Country:US
Mailing Address - Phone:770-993-2922
Mailing Address - Fax:770-993-7325
Practice Address - Street 1:3000 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5683
Practice Address - Country:US
Practice Address - Phone:770-993-2922
Practice Address - Fax:770-993-7325
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046029208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics