Provider Demographics
NPI:1043394109
Name:KUKASWADIA, MOHAMMAD ALI (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:ALI
Last Name:KUKASWADIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOHAMMAD
Other - Middle Name:
Other - Last Name:ALI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:822 RIVERTON PARK PL SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5685
Mailing Address - Country:US
Mailing Address - Phone:678-501-5420
Mailing Address - Fax:678-501-5427
Practice Address - Street 1:4904 TIMBER RIDGE DRIVE
Practice Address - Street 2:SUITE 305
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135
Practice Address - Country:US
Practice Address - Phone:678-501-5420
Practice Address - Fax:678-501-5427
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGEORGIA2084N0400X
GA0439972084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology