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General NPI Number Information
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NPI Number | 1972021962
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Entity Type | Individual
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Provider Name | OMID MIDANAKY PA-C
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Gender | Male
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Dates
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Enumeration Date | 08/30/2017
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Last Update Date | 07/30/2025
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Provider Practice Location Address
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Address Line | 2801 N DECATUR RD
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City | DECATUR
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State | GA
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Zip | 30033-5949
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Country | US
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Telephone | 404-296-5055
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Fax |
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Provider Business Mailing Address
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Address Line | 810 WHISPERWOOD TRL
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City | ACWORTH
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State | GA
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Zip | 30102-7586
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Country | US
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Telephone | 404-704-2813
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 8538
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License Number State | GA
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