Healthcare Provider Details

I. General information

NPI: 1578723177
Provider Name (Legal Business Name): HISHAM FOZI QUTOB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 04/04/2026
Certification Date: 04/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 NORTHSIDE BLVD STE 3500
CUMMING GA
30041-8223
US

IV. Provider business mailing address

1505 NORTHSIDE BLVD STE 3500
CUMMING GA
30041-8223
US

V. Phone/Fax

Practice location:
  • Phone: 770-292-3120
  • Fax: 770-292-3121
Mailing address:
  • Phone: 770-292-3120
  • Fax: 770-292-3121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number86852
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number86852
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: