Provider Demographics
NPI:1881698546
Name:GWATHNEY, MIRIAM P (DO)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:P
Last Name:GWATHNEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-1482
Mailing Address - Country:US
Mailing Address - Phone:404-301-4555
Mailing Address - Fax:404-301-4482
Practice Address - Street 1:1057 MAIN ST
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-1482
Practice Address - Country:US
Practice Address - Phone:404-301-4555
Practice Address - Fax:404-301-4482
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOS8157207Q00000X
GA063343207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261406500Medicaid
FL58945ZMedicare ID - Type Unspecified
FL261406500Medicaid