Provider Demographics
NPI:1104927565
Name:MIZRAHI, NELLY (MD)
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:
Last Name:MIZRAHI
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 1:4855 RIVER GREEN PKWY
Mailing Address - Street 2:SUITE 700
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-8336
Mailing Address - Country:US
Mailing Address - Phone:770-622-0880
Mailing Address - Fax:770-622-9875
Practice Address - Street 1:4855 RIVER GREEN PKWY
Practice Address - Street 2:SUITE 700
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8336
Practice Address - Country:US
Practice Address - Phone:770-622-0880
Practice Address - Fax:770-622-9875
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA058545OtherGA LICENSE
GA170546490AMedicaid
GA08CBBXMMedicare PIN
GA170546490AMedicaid