Healthcare Provider Details

I. General information

NPI: 1902064918
Provider Name (Legal Business Name): EATONTON PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 SPARTA HWY
EATONTON GA
31024-8484
US

IV. Provider business mailing address

PO BOX 3009
EATONTON GA
31024-3009
US

V. Phone/Fax

Practice location:
  • Phone: 706-923-0904
  • Fax: 706-923-0905
Mailing address:
  • Phone: 706-923-0904
  • Fax: 706-923-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042781
License Number StateGA

VIII. Authorized Official

Name: MUNEER AL-HAKIM
Title or Position: M.D.
Credential:
Phone: 706-923-0904