Healthcare Provider Details

I. General information

NPI: 1417120601
Provider Name (Legal Business Name): HUMZA ILYAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3379 PEACHTREE RD NE STE 500
ATLANTA GA
30326-1418
US

IV. Provider business mailing address

3379 PEACHTREE RD NE STE 500
ATLANTA GA
30326-1418
US

V. Phone/Fax

Practice location:
  • Phone: 404-591-4313
  • Fax: 678-420-7099
Mailing address:
  • Phone: 404-591-4313
  • Fax: 678-420-7099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25907
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number010101256173
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberGA64830
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number064830
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: