Provider Demographics
NPI:1386696268
Name:MULBERRY, MICHAEL JACOB (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JACOB
Last Name:MULBERRY
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 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-533-4786
Practice Address - Street 1:23 TIPTON DR
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-1603
Practice Address - Country:US
Practice Address - Phone:706-867-6505
Practice Address - Fax:706-867-6505
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050725207Q00000X
GA50725207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000938803EMedicaid
GAP00318980OtherRAILROAD MEDICARE
GAP00318980OtherRAILROAD MEDICARE
GA93BFCBGMedicare ID - Type Unspecified
GA93BFBTKMedicare PIN