Provider Demographics
NPI:1790195261
Name:MOSSADED, ELLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:
Last Name:MOSSADED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SHAHRIAR
Other - Middle Name:
Other - Last Name:MOSSADED
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3889 COBB PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4084
Mailing Address - Country:US
Mailing Address - Phone:770-975-1299
Mailing Address - Fax:
Practice Address - Street 1:3889 COBB PKWY NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101
Practice Address - Country:US
Practice Address - Phone:770-975-1299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA74500208D00000X
NYP92721208D00000X
GA074500208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice