Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 06412 | GA |
NPI | 1346454576 |
---|---|
Provider Name | Dr. Mitch E. Ergas |
First Address | Smyrna, GA 30080-1859 |
Second Address | Smyrna, GA 30080-1859 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U90065 | (02) | GA |