Provider Demographics
NPI:1326582578
Name:HESAM, MOHAMMAD REZA (DPT)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:REZA
Last Name:HESAM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4260 PEACHTREE RD NE
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3782
Mailing Address - Country:US
Mailing Address - Phone:404-400-6242
Mailing Address - Fax:
Practice Address - Street 1:4260 PEACHTREE RD NE
Practice Address - Street 2:SUITE 200A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-3782
Practice Address - Country:US
Practice Address - Phone:404-400-6242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist