Provider Demographics
NPI:1154504751
Name:BUFORD CARE INC
Entity Type:Organization
Organization Name:BUFORD CARE INC
Other - Org Name:BUFORD CARE INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHSEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODAKARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-945-4800
Mailing Address - Street 1:2721 BUFORD HIGHWAY NE
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518
Mailing Address - Country:US
Mailing Address - Phone:770-945-4800
Mailing Address - Fax:770-271-8428
Practice Address - Street 1:2721 BUFORD HIGHWAY NE
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518
Practice Address - Country:US
Practice Address - Phone:770-945-4800
Practice Address - Fax:770-271-8428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA051673207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP6216OtherMEDICARE GROUP
GA699854934AMedicaid