Provider Demographics
NPI:1285698639
Name:MARANTZ, DYLAN ISAAC (MD)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:ISAAC
Last Name:MARANTZ
Suffix:
Gender:M
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:PO BOX 491240
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30049
Mailing Address - Country:US
Mailing Address - Phone:770-751-2529
Mailing Address - Fax:770-751-2723
Practice Address - Street 1:3000 HOSPITAL BLVD
Practice Address - Street 2:PATHOLOGY DEPT
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4915
Practice Address - Country:US
Practice Address - Phone:770-751-2529
Practice Address - Fax:770-751-2723
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055129207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA565333255AMedicaid
GA565333255CMedicaid
GA565333255BMedicaid
GA565333255AMedicaid
GA565333255BMedicaid