Provider Demographics
NPI:1639380298
Name:DEL MAZO, DEANNA MULLIS (MD)
Entity type:Individual
Prefix:DR
First Name:DEANNA
Middle Name:MULLIS
Last Name:DEL MAZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DEANNA
Other - Middle Name:LYNN
Other - Last Name:MULLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3495 PIEDMONT ROAD, NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-364-7070
Mailing Address - Fax:
Practice Address - Street 1:1270 FRIENDSHIP RD
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-5630
Practice Address - Country:US
Practice Address - Phone:770-535-0191
Practice Address - Fax:770-535-0916
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102490207R00000X
GA68502207R00000X
GA068502207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003158173BMedicaid