Provider Demographics
NPI:1528003696
Name:ORDOUBADI, AIDA (DO)
Entity Type:Individual
Prefix:
First Name:AIDA
Middle Name:
Last Name:ORDOUBADI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1558 RIVERSTONE PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2888
Mailing Address - Country:US
Mailing Address - Phone:404-785-5437
Mailing Address - Fax:404-785-4683
Practice Address - Street 1:1558 RIVERSTONE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2888
Practice Address - Country:US
Practice Address - Phone:404-785-5437
Practice Address - Fax:404-785-4683
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59575208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268009200Medicaid
FL81564OtherBLUE SHIELD
FLU3819YMedicare ID - Type Unspecified
FL268009200Medicaid