Healthcare Provider Details

I. General information

NPI: 1700410867
Provider Name (Legal Business Name): REEM HUDAIB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 BRAMLETT FOREST TRL
LAWRENCEVILLE GA
30045-7281
US

IV. Provider business mailing address

1470 BRAMLETT FOREST TRL
LAWRENCEVILLE GA
30045-7281
US

V. Phone/Fax

Practice location:
  • Phone: 404-644-3669
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number20181041
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20181041
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: