Healthcare Provider Details

I. General information

NPI: 1134317316
Provider Name (Legal Business Name): AHMAD LUTFE M ABDUSSALAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

IV. Provider business mailing address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

V. Phone/Fax

Practice location:
  • Phone: 770-533-8406
  • Fax: 770-533-8409
Mailing address:
  • Phone: 770-533-8406
  • Fax: 770-533-8409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number4301080219
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number061384
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: