Provider Demographics
NPI:1053707042
Name:MILDENHALL, NICHOLAS (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MILDENHALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 CHURCH ST NE STE 340
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1131
Mailing Address - Country:US
Mailing Address - Phone:678-355-1620
Mailing Address - Fax:
Practice Address - Street 1:699 CHURCH ST NE STE 340
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1131
Practice Address - Country:US
Practice Address - Phone:678-355-1620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA84505207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program