Provider Demographics
NPI:1962493379
Name:OTHMAN, MUFID ATA (MD)
Entity Type:Individual
Prefix:
First Name:MUFID
Middle Name:ATA
Last Name:OTHMAN
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:PO BOX 4048
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4048
Mailing Address - Country:US
Mailing Address - Phone:478-254-7353
Mailing Address - Fax:478-471-6874
Practice Address - Street 1:2525 2ND ST
Practice Address - Street 2:SUITE 150
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-2223
Practice Address - Country:US
Practice Address - Phone:478-254-7353
Practice Address - Fax:478-471-6874
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020786207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000183598AHMedicaid
GA000183598AIMedicaid
GA000183598AKMedicaid
GA000183598ALMedicaid
GA000183598AFMedicaid
GA000183598AGMedicaid
GA000183598AJMedicaid
GA000183598AEMedicaid
GA000183598AMMedicaid
GA000183598ANMedicaid
GA000183598AFMedicaid
GA000183598AKMedicaid