Provider Demographics
NPI:1326055278
Name:JAN, MUJEEB A (MD)
Entity Type:Individual
Prefix:
First Name:MUJEEB
Middle Name:A
Last Name:JAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 DALLAS HWY
Mailing Address - Street 2:STE 104
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1247
Mailing Address - Country:US
Mailing Address - Phone:404-778-5543
Mailing Address - Fax:
Practice Address - Street 1:705 DALLAS HWY
Practice Address - Street 2:STE 104
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1247
Practice Address - Country:US
Practice Address - Phone:404-778-5543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054226207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF43814Medicare UPIN