Healthcare Provider Details

I. General information

NPI: 1215904834
Provider Name (Legal Business Name): JUNAID HUSSAIN MUDALIAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 01/13/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GLENLAKE PKWY KAISER PERMANENTE GLENLAKE MEDICAL CENTER
ATLANTA GA
30328-3473
US

IV. Provider business mailing address

3495 PIEDMONT RD NE NINE PIEDMONT CENTER
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 678-684-1040
  • Fax: 678-684-1045
Mailing address:
  • Phone: 404-364-7070
  • Fax: 678-684-1045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number050323
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number050323
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: