Healthcare Provider Details

I. General information

NPI: 1578849444
Provider Name (Legal Business Name): KHALDOON J AL-MOOSAWI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4245 JOHNS CREEK PKWY SUITE A
SUWANEE GA
30024-9122
US

IV. Provider business mailing address

4245 JOHNS CREEK PKWY SUITE A
SUWANEE GA
30024-9122
US

V. Phone/Fax

Practice location:
  • Phone: 678-990-3962
  • Fax: 678-840-3777
Mailing address:
  • Phone: 678-990-3962
  • Fax: 678-840-3777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number005364
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number2015-00835
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number69749
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2015-00835
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number069749
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number069749
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: