Provider Demographics
NPI:1568094951
Name:MATI, MARIAM BASIL (MD)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:BASIL
Last Name:MATI
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 1:2675 N DECATUR RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6131
Mailing Address - Country:US
Mailing Address - Phone:404-501-2900
Mailing Address - Fax:
Practice Address - Street 1:2675 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6131
Practice Address - Country:US
Practice Address - Phone:404-501-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA89811207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine