Basic Information
| Provider Information | |||||||||
| NPI: | 1386696268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULBERRY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JACOB | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705334786 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 TIPTON DR | ||||||||
| Address2: | |||||||||
| City: | DAHLONEGA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305331603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068676505 | ||||||||
| FaxNumber: | 7068676505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 050725 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 50725 | GA | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000938803E | 05 | GA | MEDICAID | P00318980 | 01 | GA | RAILROAD MEDICARE | OTHER |