Provider Demographics
NPI:1528168747
Name:MAVROMATIS, JULIET KOTTAK (MD)
Entity type:Individual
Prefix:DR
First Name:JULIET
Middle Name:KOTTAK
Last Name:MAVROMATIS
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 1:57 EXECUTIVE PARK S
Mailing Address - Street 2:STE 390
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2288
Mailing Address - Country:US
Mailing Address - Phone:404-997-6790
Mailing Address - Fax:
Practice Address - Street 1:57 EXECUTIVE PARK S
Practice Address - Street 2:STE 390
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2288
Practice Address - Country:US
Practice Address - Phone:404-997-6790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043699207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG60244Medicare UPIN