Provider Demographics
NPI:1447893789
Name:MARS, MAKEDA DAMALI MOGERIE (RDN LD)
Entity type:Individual
Prefix:
First Name:MAKEDA
Middle Name:DAMALI MOGERIE
Last Name:MARS
Suffix:
Gender:F
Credentials:RDN LD
Other - Prefix:
Other - First Name:MAKEDA
Other - Middle Name:DAMALI
Other - Last Name:MOGERIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN LD
Mailing Address - Street 1:3640 FAIRBURN PL NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-1422
Mailing Address - Country:US
Mailing Address - Phone:404-735-4655
Mailing Address - Fax:
Practice Address - Street 1:3640 FAIRBURN PL NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-1422
Practice Address - Country:US
Practice Address - Phone:404-735-4655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004203133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered