Provider Demographics
NPI:1902064595
Name:DUNWOODY PROFESSIONAL MEDICAL INC
Entity Type:Organization
Organization Name:DUNWOODY PROFESSIONAL MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MOINUDDIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-455-8285
Mailing Address - Street 1:2803 PRIESTCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-2195
Mailing Address - Country:US
Mailing Address - Phone:770-455-8285
Mailing Address - Fax:770-350-8973
Practice Address - Street 1:4480 N SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-6410
Practice Address - Country:US
Practice Address - Phone:770-455-8285
Practice Address - Fax:770-350-8973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042868261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000776432EMedicaid
GA08BBVTGMedicare PIN