Healthcare Provider Details

I. General information

NPI: 1942725544
Provider Name (Legal Business Name): DEYA ALDEEN MOHAMMAD ALI ALKHATIB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2017
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST # OR6000
AUGUSTA GA
30912-3220
US

IV. Provider business mailing address

768 NUTTALL ST
EVANS GA
30809-0838
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-8623
  • Fax:
Mailing address:
  • Phone: 410-225-8790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number75291
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number98012
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME176907
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: