Healthcare Provider Details

I. General information

NPI: 1366639221
Provider Name (Legal Business Name): SYEDA MAIMUNA ALI KHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 NEWNAN CROSSING BYP
NEWNAN GA
30263-2384
US

IV. Provider business mailing address

710 NEWNAN CROSSING BYP STE 200
NEWNAN GA
30263-2384
US

V. Phone/Fax

Practice location:
  • Phone: 770-487-7807
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number86127
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: