Provider Demographics
NPI:1689766743
Name:SOUMA, JOHN AZIZ (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:AZIZ
Last Name:SOUMA
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 1:310 HOSPITAL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3895
Mailing Address - Country:US
Mailing Address - Phone:478-741-8862
Mailing Address - Fax:478-633-5016
Practice Address - Street 1:310 HOSPITAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3895
Practice Address - Country:US
Practice Address - Phone:478-741-8862
Practice Address - Fax:478-633-5016
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14218174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD30867Medicare UPIN