Healthcare Provider Details

I. General information

NPI: 1861486557
Provider Name (Legal Business Name): KHAWAJA R MAHMOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 SAMMY MCGHEE BLVD STE 102
JASPER GA
30143-4093
US

IV. Provider business mailing address

12 SAMMY MCGHEE BLVD STE 102
JASPER GA
30143-4093
US

V. Phone/Fax

Practice location:
  • Phone: 706-253-9898
  • Fax: 706-253-9896
Mailing address:
  • Phone: 706-253-9898
  • Fax: 706-253-9896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number042648
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: