Provider Demographics
NPI:1548573884
Name:KUKASWADIA P.C.
Entity Type:Organization
Organization Name:KUKASWADIA P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KUKASWADIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-501-5420
Mailing Address - Street 1:822 RIVERTON PARK PL SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5685
Mailing Address - Country:US
Mailing Address - Phone:678-501-5420
Mailing Address - Fax:
Practice Address - Street 1:4904 TIMBER RIDGE DR
Practice Address - Street 2:SUITE 305
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1828
Practice Address - Country:US
Practice Address - Phone:678-501-5420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-15
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA439972084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000757985LMedicaid
GA000757985LMedicaid