Provider Demographics
NPI:1518953785
Name:FATTOUH, YARA (MD)
Entity Type:Individual
Prefix:DR
First Name:YARA
Middle Name:
Last Name:FATTOUH
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:P.O. BOX 1383
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705
Mailing Address - Country:US
Mailing Address - Phone:706-695-5500
Mailing Address - Fax:706-695-5512
Practice Address - Street 1:1111 HWY 76
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705
Practice Address - Country:US
Practice Address - Phone:706-695-5500
Practice Address - Fax:706-695-5512
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA53522207Q00000X
GA053522207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA270193875OtherTA ID NUMBER
GA837893819AMedicaid
GA08BBQKWMedicare ID - Type UnspecifiedMEDICARE NUMBER
GA270193875OtherTA ID NUMBER