Provider Demographics
NPI:1902064918
Name:EATONTON PEDIATRICS
Entity Type:Organization
Organization Name:EATONTON PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:MUNEER
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-HAKIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-923-0904
Mailing Address - Street 1:PO BOX 3009
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-3009
Mailing Address - Country:US
Mailing Address - Phone:706-923-0904
Mailing Address - Fax:706-923-0905
Practice Address - Street 1:116 SPARTA HWY
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-8484
Practice Address - Country:US
Practice Address - Phone:706-923-0904
Practice Address - Fax:706-923-0905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042781208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA611384188AMedicaid
GA733076132AMedicaid