Provider Demographics
NPI:1083713069
Name:MUDAHAR, BALJINDER (MD)
Entity Type:Individual
Prefix:
First Name:BALJINDER
Middle Name:
Last Name:MUDAHAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 WASHITA AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-1943
Mailing Address - Country:US
Mailing Address - Phone:301-257-1999
Mailing Address - Fax:
Practice Address - Street 1:1052 WASHITA AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-1943
Practice Address - Country:US
Practice Address - Phone:301-257-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054321207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA063835622JMedicaid
GA063835622JMedicaid