Provider Demographics
NPI:1295099018
Name:FATAKHOV, EDUARD (MD)
Entity type:Individual
Prefix:DR
First Name:EDUARD
Middle Name:
Last Name:FATAKHOV
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 1:401 S MAIN ST STE B3
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-1958
Mailing Address - Country:US
Mailing Address - Phone:404-836-9906
Mailing Address - Fax:470-545-4768
Practice Address - Street 1:401 S MAIN ST STE B3
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-1958
Practice Address - Country:US
Practice Address - Phone:404-836-9906
Practice Address - Fax:470-545-4768
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005563207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine