Healthcare Provider Details

I. General information

NPI: 1467017038
Provider Name (Legal Business Name): KHATIJA SULTANA AHMED DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 MULKEY RD
AUSTELL GA
30106-1182
US

IV. Provider business mailing address

1350 UPPER HEMBREE RD STE 100
ROSWELL GA
30076-0929
US

V. Phone/Fax

Practice location:
  • Phone: 707-455-1017
  • Fax: 678-239-0994
Mailing address:
  • Phone: 678-426-2171
  • Fax: 404-446-1957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD001530
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: