Healthcare Provider Details

I. General information

NPI: 1760123046
Provider Name (Legal Business Name): FARES HOSSEINZADEH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2022
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11180 STATE BRIDGE RD STE 404
ALPHARETTA GA
30022-7484
US

IV. Provider business mailing address

11180 STATE BRIDGE RD STE 404
JOHNS CREEK GA
30022-7484
US

V. Phone/Fax

Practice location:
  • Phone: 770-252-2220
  • Fax:
Mailing address:
  • Phone: 770-252-2220
  • Fax: 855-538-3133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number105392
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: