Healthcare Provider Details

I. General information

NPI: 1730884768
Provider Name (Legal Business Name): ABDULMOIZ KAISER ABDULWALI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2023
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 BAXTER ST
ATHENS GA
30606-3712
US

IV. Provider business mailing address

1230 BAXTER ST
ATHENS GA
30606-3712
US

V. Phone/Fax

Practice location:
  • Phone: 706-389-3410
  • Fax: 706-389-3411
Mailing address:
  • Phone: 706-389-3410
  • Fax: 706-389-3411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number111882
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: