Provider Demographics
NPI:1881072940
Name:POORAK, MITRA (MD)
Entity type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:POORAK
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 1:1444 VALLEY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-4825
Mailing Address - Country:US
Mailing Address - Phone:404-516-1024
Mailing Address - Fax:
Practice Address - Street 1:1301 SIGMAN RD NE STE 180
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3924
Practice Address - Country:US
Practice Address - Phone:770-922-4024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-09
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008421208600000X
IL036-161760208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery