Provider Demographics
NPI:1417980798
Name:HAROON, EBRAHIM (MD)
Entity Type:Individual
Prefix:
First Name:EBRAHIM
Middle Name:
Last Name:HAROON
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 1:101 WOODRUFF CIR
Mailing Address - Street 2:SUITE 4105
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-0001
Mailing Address - Country:US
Mailing Address - Phone:404-712-2890
Mailing Address - Fax:
Practice Address - Street 1:101 WOODRUFF CIR
Practice Address - Street 2:SUITE 4105
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-0001
Practice Address - Country:US
Practice Address - Phone:404-712-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC510462084P0800X
GA597332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C510460OtherMEDI-CAL
CA00C510460OtherMEDI-CAL
CAWC51046AMedicare ID - Type Unspecified