Healthcare Provider Details

I. General information

NPI: 1821212390
Provider Name (Legal Business Name): AMITA KETAN GHIA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 ATLANTA HWY STE 105
CUMMING GA
30040-6339
US

IV. Provider business mailing address

1754 MORNINGDALE CIR
DULUTH GA
30097-5260
US

V. Phone/Fax

Practice location:
  • Phone: 770-203-1000
  • Fax:
Mailing address:
  • Phone: 678-473-0715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number61431
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: