Healthcare Provider Details

I. General information

NPI: 1295724383
Provider Name (Legal Business Name): MOHAMED MIDANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 N MEDICAL PKWY
WOODSTOCK GA
30189-7031
US

IV. Provider business mailing address

2230 TOWNE LAKE PKWY BUILDING 300, SUITE 100
WOODSTOCK GA
30189-5540
US

V. Phone/Fax

Practice location:
  • Phone: 770-517-1900
  • Fax:
Mailing address:
  • Phone: 770-517-1900
  • Fax: 770-926-3215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number019080
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: