Provider Demographics
NPI:1629807136
Name:MOYO, EDWIN
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:MOYO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NORTHSIDE DR NW STE A71128
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-2673
Mailing Address - Country:US
Mailing Address - Phone:404-593-3666
Mailing Address - Fax:
Practice Address - Street 1:4989 THOMPSON MILL RD
Practice Address - Street 2:
Practice Address - City:STONECREST
Practice Address - State:GA
Practice Address - Zip Code:30038-2334
Practice Address - Country:US
Practice Address - Phone:404-593-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABL24-000204172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker