Healthcare Provider Details

I. General information

NPI: 1568094951
Provider Name (Legal Business Name): MARIAM BASIL MATI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 08/30/2021
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 N DECATUR RD
DECATUR GA
30033-6131
US

IV. Provider business mailing address

2675 N DECATUR RD
DECATUR GA
30033-6131
US

V. Phone/Fax

Practice location:
  • Phone: 404-501-2900
  • Fax:
Mailing address:
  • Phone: 404-501-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number89811
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: