Provider Demographics
NPI:1295764009
Name:KHAJA, NIZAMUDDIN (MD)
Entity type:Individual
Prefix:
First Name:NIZAMUDDIN
Middle Name:
Last Name:KHAJA
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 1:119 AMBULANCE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-812-3530
Mailing Address - Fax:
Practice Address - Street 1:101 QUARTZ DR # 103
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3255
Practice Address - Country:US
Practice Address - Phone:770-812-3530
Practice Address - Fax:770-812-3531
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0549152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
26BDJVZMedicare ID - Type Unspecified
G89289Medicare UPIN