Provider Demographics
NPI:1639173248
Name:HIMOT, EDWARD DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:DAVID
Last Name:HIMOT
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 1:55 WHITCHER ST NE
Mailing Address - Street 2:STE 460
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1171
Mailing Address - Country:US
Mailing Address - Phone:770-427-7389
Mailing Address - Fax:770-427-2845
Practice Address - Street 1:55 WHITCHER ST NE
Practice Address - Street 2:STE 460
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1171
Practice Address - Country:US
Practice Address - Phone:770-427-7389
Practice Address - Fax:770-427-2845
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018388174400000X
GAGA018388207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000135231FMedicaid
GA000135231TMedicaid
GA000135231UMedicaid
GA000135231HMedicaid
GA000135231YMedicaid
GA000135231LMedicaid
GA000135231VMedicaid
GA000135231MMedicaid
GA00135231AMedicaid
GA000135231JMedicaid
GA000135231KMedicaid
GA000135231WMedicaid
GA000135231RMedicaid
GA000135231XMedicaid
GA000135231EMedicaid
GA000135231SMedicaid
GA000135231RMedicaid